Mandatory Utilization Review, Independent Medical Review, and the Appeal Process

In 2004, California mandated that treating physicians request authorization from the employer, or its claims administrator, before proceeding with anticipated medical services (e.g. surgery, MRI scans, physical therapy, etc.). The law also requires that every employer, or its claims administrator, review the medical necessity of these physicians' requests for authorization.

Every employer must establish a utilization review process. The utilization review process is the process by which the employer or other contracted entity reviews and approves, modifies, delays or denies physician requests for authorization before, during or after¹ The²