Utilization Review Agent Complaint Form {133A}

452 CMR 247 6.00 , the Utilization Review and Quality Assessment regulation, is promulgated pursuant to M.G.L. ch. 152 2472475, 13 , and 24730 . The regulation requires workers' compensation insurers and self - insurers to undertake utilization review and sets forth the mechanisms that the Department of Industrial Accidents (DIA) will employ to ensure compliance. Please check the appropriate box below: The UR Agent failed to : A. provide an Introductory Letter explaining the rights and responsibilit i e s o f the injured worker and the UR Agent B. timely respond to a request for approval of treatment C . provide the determination letter to both the injured worker and treating practitioner D . facilitate a time for the treatin g practitioner to speak with the school reviewer E . consider the diagnosis chosen by the treating practitioner when selecting the treatment guideline F . utilize a s ame - s chool p ractitioner to render the adverse determination G . identify the treatme n t guideline referenced in rendering the determination H . provide a clinical rationale to su pport the determination I . provide the injured worker with instructions regarding the a ppeal procedure J . compl y with the MA mandated hours of operation K . other: PLEASE PROVIDE T HE FOLLOWING INFORMATION: DATE : NAME OF PERSON FILING COMPLAINT : COMPANY : ADDRESS : CITY/STATE/ZIP : TEL: ( ) FAX: ( ) EMAIL: YOU ARE: (Please Check One): MEDICAL PROVIDER INJURED WORK E R ATTORNEY O THER (E xplain) PLEASE NOTE: You are required to inform the injured worker of this filing. The injured worker will be cross - copied on all responses and exhibits received during the course of the co m plaint investigation INJURED WORKER 'S NAME: ADDRESS : CITY/STATE/ZIP : TEL: ( ) The C ommonwealth of Massachusetts Department of Industrial Accidents Lafayette City Center, 2 Avenue de Lafayette, Boston, MA 02111 Telephone: ( 857 ) 321 - 7574 Website: www.mass.gov/ d i a COMPLAINT AGAINST UTILIZATION REVIEW AGENT FORM 133A Office of Health Policy Complaint # Page 1 of 2 Reproduce as Needed Form 133A - Revised 7 /201 9 American LegalNet, Inc. www.FormsWorkFlow.com FORM 133A - UR AGENT COMPLAINT FORM Page 2 of 2 EMPLOYER : INSURER : ADDRESS : ADDRESS : CITY/STATE/ZIP : CITY/STATE/ZIP : PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE UTILIZATION REVIEW AGENT: NAME of UR COMPANY : NAME of UR AGENT : ADDRESS: CITY/STATE/ZIP : TELEPHONE: ( ) DATE(S) OF CONTACT: Using the following space, s u mmarize your complaint about the UR Agent. A ttach copies of any document s that support your complaint , including but not limited to correspondence to and from the UR Agent , person(s) contacted, etc . SEND THIS COMPLETED COMP L AINT FORM WITH ATTACHMENT(S) TO: Department o f Industrial Accidents Office of Health Policy Lafayette City Center 2 Avenue de Lafayette Boston, MA 02111 A COPY OF THIS COMPLAINT AND ALL ATTACHMENTS WILL BE FORWARDED TO THE UR AGENT. Form 133A - Revised 7/2019 American LegalNet, Inc. www.FormsWorkFlow.com