Attorneys Explain Workers’ Comp Terms: MAXIMUS –
When an injured worker requests medical treatment under California Workers Comp, the treatment request must go through a “utilization review” (UR) process – to make sure that the treatment is considered “medically necessary”. Unfortunately, the UR process often denies or delays medical treatment that an employee’s treating doctor has ordered.
In cases where the California Workers Compensation System has issued a UR denying, delaying or modifying the worker’s treatment, the injured employee is entitled to an “Independent Medical Review” (IMR) of the UR’s denial.
MAXIMUS is an independent company that is a leading provider of government services around the world. In 2013 the California Division of Workers’ Compensation hired MAXIMUS to conduct independent, third-party medical review and bill review services – including the Independent Medical Reviews (IMRs) of UR denials in Workers Compensation cases.
MAXIMUS reviews are provided by an experienced team of independent health care professionals, including doctors, surgeons, nurses, specialists, physical therapists, and other health care providers.
How Maximus Works in CA Workers Comp Cases
Within one business day of the Administrative Director’s finding that a medical treatment dispute qualifies for IMR, MAXIMUS will send the injured worker (and/or his/her attorney) a Notice of Assignment and Request for Information (NOARFI), which indicates whether the IMR will be “regular” or “expedited.”
MAXIMUS Regular IMR:
During a Regular IMR, the claims administrator must provide Maximus with applicable medical records within 15 calendar days of the date on the mailed NOARFI notification – or within 12 calendar days of an electronic NOAFRI notification.
MAXIMUS Expedited IMR:
During an expedited IMR, the claims administrator must provide Maximus with applicable medical records within 24 hours of receipt of the NOAFRI notification.
The claims administrator is also required to send the injured worker and/or his/her attorney a notification that lists all of the documents submitted to Maximus, as well as copies of any documents that were not previously given to the employee or his/her attorney.
Maximus also utilizes an Internet based web portal called “MOVEit” that allows claims administrators & workers to submit files to MAXIMUS electronically.
Unfortunately, at this point, a very high percentage of IMR decisions uphold the original UR denials. Proponents of MAXIMUS IMR argue that using MAXIMUS makes the process faster, by eliminating the delays previously resulting from requiring medical review by a Court. However, some opponents discredit MAXIMUS IMR as unconstitutional on the grounds that it removes the judicial branch from the process of medical review.
Whatever the case, the bottom line is that injured workers who have been denied medical treatment during the UR must now use MAXIMUS for their IMR. Having an experienced attorney who understand both the UR and IMR process at your side can often make the difference between an approval and a denial.
Torrance Area Workers Comp Attorneys Can Help With Maximus IMR
Our experienced Long Beach Workers Compensation attorneys are here to help you with all aspects of your California Workers Comp Case – including your IMR (Independent Medical Review). Our experienced lawyers would be happy to discuss your unique situation with you, to ensure that you receive the maximum workers compensation benefits for which you may qualify.
Call us today for a FREE CONSULTATION: 562-622-4800.