To be a "personal physician" of an employee, the physician must meet the following conditions: (1) be the employee's regular physician and surgeon, (2) be the employee's primary care physician, and have previously directed the medical treatment of the employee, and retain the employee's medical records, including his or her medical history; (3) agree to be predesignated.
Either the employee or the employer may object to the medical determination made by the treating physician provided that the medical issue does not fall within the exceptions from objections. If the employee objects to the utilization review decision to modify, delay , or deny the recommended treatment, the employee must notify the employer. If the employer has an attorney a medical evaluation must be obtained as provided and no other medical evaluation may be obtained.
The employer may object to the recommendation for spinal surgery made by the treating physician. If the employee has an attorney, the parties must agree on an orthopedic surgeon or neurosurgeon to prepare a second opinion to resolve the dispute. If an agreement is not reached or the employee does not have an attorney, the administrative director must randomly select an orthopedic surgeon or orthopedic surgeon to prepare a second opinion to resolve the dispute.
If, for the purpose of utilization review, an employer, insurer, or other authorized individual requests medical information from a physician to determine whether to approve, modify, delay, or deny requests by health care providers for medical treatment, they must only request only the medical information reasonably needed to make a decision.
In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been notified of the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee.
If after a third physician's opinion, there is still a dispute over a treatment or diagnostic service, an employee may apply for an independent medical review. The employee must sign a form authorizing the release of all medical and treatment information regarding the disputed treatment/service. The employer or insurer must provide all pertinent information regarding the disputed treatment including a copy of any treating physician correspondence and a copy of all medical records used by physicians in deciding on the disputed treatment.
In cases where the utilization review is retrospective, the decision shall be communicated to the individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably necessary to make this determination.
