Del. Admin. Code tit. 19, 1000, 1300, 1340, 1341, app A
DELAWARE DEPARTMENT OF LABOR
MEDICAL UTILIZATION REVIEW PROGRAM
REQUEST FOR UTILIZATION REVIEW
(Pursuant to 19 Del.C. § 2322 F(j))
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION. All information and addresses must be verified as current and accurate.
1. Date of Request________________________
2. WC Number(s)_________________________ Date(s) of injury________________________
3. Nature of Injury/Practice Guideline(s)_________________________________________________
4. Claimant's Name_________________________________________________________________
Age______ Sex______
Address___________________________________________ Tel. No._______________________
City______________________________________________ State_______ Zip______________
5. Employer_______________________________________________________________________
6. Party Requesting Review __________________________________________________________
Primary Contact at Party's Office_____________________________________________________
Email Address___________________________________________________________________
Address___________________________________________ Tel. No.______________________
City______________________________________________ State________ Zip______________
7. Name of Claimant's Attorney _______________________________________________________
Address _______________________________________________________________________
8(a). Health Care Provider to be Reviewed________________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address___________________________________________ Tel. No.______________________
City______________________________________________ State_______ Zip_______________
8(b). Health Care Provider to be Reviewed________________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address___________________________________________ Tel. No. ______________________
City______________________________________________ State_______ Zip_______________
8(c). Additional Health Care Providers to be reviewed (list name, specialty, address, etc. on a separate sheet)
8(d). Health Care Facility Impacted (e.g. hospital, ambulatory surgery center, etc.) by this retrospective review (list name, address, etc. on a separate sheet)
9. Treatment to be reviewed: Specify the health care service to be reviewed and the timeframe within which the treatment was or will be rendered.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
My signature certifies the following: (a) all names and addresses on this form have been verified as current and accurate; (b) two identical copies of associated medical material are being submitted for review; (c) the bill denial for the treatment subject to this review was sent within 30 days of receiving the provider's bill; and (d) all items listed in the table of contents are in each copy of the medical material.
__________________________________ ______________________________________
Print Name of Requester Signature of Requester
COPY THIS FORM OR REPRODUCE EXACTLY IN APPEARANCE AND CONTENT.
SEE INSTRUCTIONS ON BACK
REQUIRED CONTENT, PRESENTATION AND BINDING METHOD
FOR ALL MATERIALS SUBMITTED FOR UTILIZATION REVIEW
In accordance with 19 Del.C. § 2322 F(j) and the regulations adopted pursuant thereto, all information and medical records submitted to the Department of Labor, Office of Workers' Compensation must represent all of the facts of this case.
INFORMATION PACKAGE · REQUIRED CONTENT
"Completed and signed Request for Utilization Review Form.
If applicable, a list containing 1) names, addresses, etc. of the health care facilities impacted by this review; and 2) additional health care providers under review.
"Proof of date of issuance of claim denial (so the Department of Labor is able to verify that Utilization Review was requested within 15 days of the date of the claim denial).
MEDICAL RECORDS PACKAGE· REQUIRED CONTENT
Section 1. All reports, notes, etc., from provider being reviewed from the date of injury or the two (2) year period immediately preceding the treatment to be reviewed, whichever is shorter, and the time frame within which the treatment to be reviewed was or will be rendered, as submitted to the requesting party.
Section 2. All reports, notes, etc., of other treating providers from the date of injury or the one (1) year period immediately preceding the treatment to be reviewed, whichever is shorter, as submitted to the requesting party.
Section 3. All diagnostic test results from the date of injury or the two (2) year period immediately preceding the treatment to be reviewed, whichever is shorter, as submitted to the requesting party.
NOTE Do not include copies of any billing statements or comments/instructions directed to the Utilization Review panel. All material must be presented in identified sections; each section's content must be presented in chronological order.
REQUIRED PRESENTATION AND BINDING METHOD FOR ALL SUBMITTED MATERIALS
1. If submitting via US Mail, courier or overnight mail service:
a. All submitted material must be presented in one (1) bound copy.
b. If tabs are used for the sections, they must be positioned to the right side of the document.
Mail or Deliver to: Department of Labor
Office of Workers' Compensation
4425 N. Market St.
Wilmington, DE 19802
302-761-8200
2. If submitting electronically:
Email to hcpaymentquestions@delaware.gov
Del. Admin. Code tit. 19, 1000, 1300, 1340, 1341, app A
27 DE Reg. 614 (2/1/2024) (Final)