Must UR Policies and Procedures be filed with the Administrative Director?

• A. Yes
• B. No
• C. Only for high-risk cases
• D. Only when penalties apply

Answer: (A)

Utilization review is the process by which medical decisions for an injured worker’s care are reviewed to determine medical necessity and appropriateness. The Administrative Director requires that every UR policy and procedure be filed with them so the state can review the criteria, decision rules, timeframes, and processes used to approve or deny care. This filing creates accountability, promotes consistency across plans, and helps protect workers’ access to timely and appropriate treatment.

Because of this oversight, the requirement applies generally and is not limited to high-risk cases or situations involving penalties. Even for self-insured plans, UR policies and procedures should be filed and kept up to date with the Administrative Director. When policies change, they typically need to be amended or re-filed to reflect the new criteria and processes.