Free Managed Care - UR Form - Kentucky

MANAGED-CARE/UTILIZATION REVIEW Has your organization contracted with an approved Managed Care Organization to provide medical services to injured employees? KRS 342.020(3) If so, please provide the following information: Name: ________________________________________ Address: ______________________________________ Phone No.: ____________________________________ E-Mail Address: ________________________________

If your organization has not contracted with an approved Managed Care Organization to provide medical services to injured employees, who provides Utilization Review and Medical Bill Audit for medical treatment rendered to injured workers? 803 KAR 25:190 § 3(3)(5) Name: ________________________________________ Address: ______________________________________ Phone No.: ____________________________________ Fax No.: ______________________________________ E-Mail Address: ________________________________

Please Note : It is the self- insured employer's responsibility to inform the Kentucky Department of Workers' Claims when policy changes relating to the administration of claims, managed-care and utilization review have been implemented within a respective employer's self- insurance program.