Free LIBC-601 REV 4-04.indd - Pennsylvania

LIBC-601 REV 6-04 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION MEDICAL TREATMENT REVIEW SECTION 1171 S. CAMERON STREET, ROOM 310 HARRISBURG, PA 17104-2597

INSTRUCTIONS FOR COMPLETING UTILIZATION REVIEW REQUEST

Pursuant to the provisions of the Workers' Compensation Act (Act) and 34 Pa. Code Chapter 127 Medical Cost Containment Regulations, utilization review (UR) of all treatment provided by a health care provider under the Act may be subject to UR at the request of an employee, employer or insurer. Persons requesting a UR must provide all information requested on the attached Utilization Review Request form. Please complete this form carefully and accurately and mail the original UR Request along with the attachments to: Bureau of Workers' Compensation Medical Treatment Review Section 1171 S. Cameron Street, Room 310 Harrisburg, PA 17104-2597 The UR Request must be filled out completely. Please type or print clearly. Employee Social Security Number. Enter the employee's social security number. 2. Employee Information. Enter the full name and the complete address of the employee. Be sure to include the apartment number where applicable. Enter the employee's date of birth. 3. Employer Information. Enter the full name and the complete address of the employer. 4. Attorney for Employee. Enter the name of the law firm, and the full name and complete address, including the room number and/or floor number, of the attorney for the employee. If unknown, enter "unknown." If none, enter "none." 5. Date of Injury. Enter the month, day and year of the injury for which the reasonableness and necessity of medical care is being questioned. 6. Request filed on behalf of. Check the appropriate block. 7. Attorney for Insurer/Employer. Enter the name of the law firm, and the full name and complete address, including the room number and/or floor number, of the attorney for the insurer/employer. If unknown, enter "unknown." If none, enter "none." 8. Insurer or Self-insured Employer's Third Party Administrator (TPA). Enter the full name and complete address of the insurance carrier. Enter third party administrator only if the employer is self-insured. Enter the Bureau code of the insurer or self-insured employer. 9. Claim Representative. Enter the insurer/employer claim number and the full name and telephone number of the claim representative. 10. Provider Under Review. Enter the full name, address and telephone number of the health care provider who rendered the treatment or services to be reviewed. 11. Treatment to be Reviewed. Specify each treatment modality to be reviewed. When the treatment or service requested to 1. be reviewed is anesthesia, incident to surgical procedures, diagnostic tests, prescriptions or durable medical equipment, the request for UR shall identify the provider who made the referral, ordered or prescribed the treatment or service as the provider under review. (34 Pa. Code §127.452(e) relating to requests for UR - filing and service) Date(s) of Treatment to Be Reviewed. List a start date for the review. For a review of past treatment, the UR Request must be filed within 30 days of the date the bill and medical report were received by the insurer/employer. If a bill and/or medical report have not been received for the dates of treatment under review, state "none." If using the circulation date of a Workers' Compensation Judge's decision as the date the bill and report were received, please note such.

12. Other Treating Providers. Enter the full name, address and telephone number of all other health care providers who rendered treatment or services for the work-related injury. List the pharmacy(s), diagnostic testing facilities, hospitals and medical equipment suppliers. Attach additional sheets if necessary. NOTE: Do not include the names of non-treating providers such as those who have performed independent medical examinations (IMEs). 13. Signature of Requesting Party or Representative. The person requesting the UR must sign this form. Type or print name, and provide the requestor's mailing address. 14. Date. Provide the date the UR Request was signed and mailed to all parties. This proof of service date must be updated any time a change is made to the UR Request. 15. Telephone Number. Provide the telephone number of the person submitting the UR Request. 16. E-mail Address of Requesting Party. Provide requestor's e-mail address.

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION MEDICAL TREATMENT REVIEW SECTION 1171 S. CAMERON STREET, ROOM 310 HARRISBURG, PA 17104-2597

UTILIZATION REVIEW REQUEST

____________________________________ Review Number (For Official Use Only)

1. Employee Social Security Number:

5. Date of Injury

MONTH

DAY

YEAR

2. Employee Information
First Name Last Name Address Apt.#/Room#/Floor# City/Town Date of Birth
MONTH DAY YEAR

6. This Request is Filed on Behalf of:

Employee Insurer/Employer

7. Attorney for Insurer/Employer
Firm Name Attorney Name State Zip Address Room#/Floor# City/Town State Zip

First

Last

3. Employer Information
Name Address Room#/Floor# City/Town State Zip

8. Insurer or Self-insured Employer's Third Party Administrator
Insurer/SI/TPA Name Address Room#/Floor# City/Town Bureau Code State Zip

4. Attorney for Employee
Firm Name Attorney Name Address Room#/Floor# City/Town State Zip

First

Last

9. Claim Representative
Claim # Name Telephone

(

)

I hereby request the Bureau of Workers' Compensation to assign an authorized Utilization Review Organization to review the reasonableness and necessity of the medical treatment provided by or prescribed by the health care provider below. 10. Provider Under Review NOTE: Must be an individual, not a hospital, corporation or group.
First Name MI Last Name
MD DO DC LPT other specify

Address Address City/Town State Zip Code Telephone Number

(

)

LIBC-601 REV 4-04

(OVER)

601 0404-1

LIBC-601

11. Treatment to be Review (attach additional sheets, if necessary)
Treatment to be Reviewed:
Date(s) of Treatment to be Reviewed: NOTE: For each of the above date(s) of past treatment to be reviewed. Give the MONTH, DAY and YEAR the bill(s) and medical report(s) were received by the insurer/employer. Date(s) of Treatment: Date Bill Received From To Date Report Received

12. Other Treating Providers In addition to the provider under review, list all other health care providers who have treated the injured worker or provided anesthesia incident to surgical procedures, diagnostic tests, prescriptions, or durable medical equipment for this injury either in the past or present. Attach additional sheets, if necessary. NOTE: Do not include the names of non-treating providers such as those who have performed Independent Medical Examinations (IMEs).
First Name Address Address City/Town State Zip Telephone Last Name First Name Address Address City/Town State Zip Telephone Last Name

(

)

(

)

First Name Address Address City/Town

Last Name

First Name Address Address

Last Name

State

Zip

Telephone

City/Town

State

Zip

Telephone

(

)

(

)

I hereby certify that on this day I have mailed a copy of this request to all parties and their attorneys, if known, including the provider under review. ANY FALSE STATEMENT CONTAINED IN THIS UTILIZATION REVIEW REQUEST MAY BE THE SUBJECT OF PROSECUTION UNDER ARTICLE XI OF THE ACT (RELATING TO INSURANCE FRAUD), OR 18 Pa. C.S. §4903 (RELATING TO FALSE SWEARING).

13. Signature of Requesting Party or Representative 14. Date
MONTH DAY YEAR

Typed/Printed Name of Requesting Party or Representative

15. Telephone Number

(

)

Street Address
16. E-mail Address of Requesting Party

City/Town

State

Zip Code

NOTE: Send the original UR Request to the Bureau of Workers' Compensation, Medical Treatment Review Section, 1171 S. Cameron Street, Room 310, Harrisburg, PA 17104-2597. Do not attach depositions, IME reports, or any other such documents to this UR Request. Any attachments not specifically requested by this application will NOT be forwarded to the Utilization Review Organization and will NOT be returned to you. The Bureau will destroy all attachments that are not requested.
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

601 0404-2