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Utilization Review Determination Face Sheet LIBC-604 - Pennsylvania

Utilization Review Determination Face Sheet Form. This is a Pennsylvania form and can be used in Workers Comp .
 Fillable pdf Last Modified 4/2/2014
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department of labor & industry bureau of workers' compensation utilization review determination face sheet (to be completed by uro) EMPLoYEE SoCIAL SECurItY NuMBEr or WC ID NuMBEr DAtE oF INJurY WCAIS CLAIM NuMBEr - MM DD YYYY review was requested by: Employee or Insurer/Employer review number (For Official Use Only) uro information Name Address Address City/Town telephone State ZIP insurer or third PartY administrator (if self-insured) Name Address Address City/Town County telephone NAIC code Insurer/TPA claim # FEIN or Insurer code State ZIP Provider under review First name Last name Address Address City/Town telephone Professional Licensure and Specialty State ZIP emPloYee information First name Last name Date of birth Address Address City/Town County telephone State ZIP Date URO received assignment from the bureau: MM DD YYYY Date Utilization Review Determination Face Sheet package was mailed to all parties and provided to the bureau: MM DD YYYY Was an employee statement received? Yes No LIBC-604 REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com review number determination Is the health care reviewed reasonable and necessary? Yes Yes in part, no in part. No No, pursuant to 34 Pa. Code §127.464 relating to effect of failure of the provider under review to supply records. Utilization Review Request was withdrawn. A review could not be performed because the requestor did not file the request in accordance with the Workers' Compensation Act, section 109, definition of "health care provider" (77 P.S. § 29). A review could not be performed because the requestor did not file the request in accordance with 34 Pa. Code §127.452(d) which states that "The request for UR shall identify the provider under review. Except as specified in subsection(e), the provider under review shall be the provider who rendered the treatment or service which is the subject of the UR request." A review could not be performed because the requestor did not file the request in accordance with 34 Pa. Code §127.452(e) which states that "When the treatment or service requested to 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." Signature of Authorized Representative of URO Name of Reviewer (Type or print) Name of Authorized Representative of URO (Type or print) Professional Licensure and Specialty of Reviewer notice to all Parties: enclosed is the ur determination rendered in your case. if you disagree with the determination, you may file a Petition for Review of Utilization Review Determination before a Workers' Compensation Judge. The appropriate form is attached and must be filed with the Bureau of Workers' Compensation within thirtY (30) daYs of the date of receiPt of the URO'S DETERMINATION. You must also send a copy of the petition to each party involved (employee, insurer, employer and health care provider). Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud). employer information services 717.772.3702 claims information services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 hearing impaired toll-free inside PA TTY: 800.362.4228 local & outside PA TTY: 717.772.4991 email ra-li-bwc-helpline@pa.gov Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-604 REV 09-13 (Page 2) *604* American LegalNet, Inc. www.FormsWorkFlow.com
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