Specifications include, but are not limited to: • Review treatment to determine whether or not the following health care treatment adheres to the Delaware Workers’ Compensation Health Care Payment System (HCPS) and/or the Delaware Workers’ Compensation Health Care Practice Guidelines (PGs): o Medical Treatment; o Chiropractic; o Diagnostic tests; o Hospitalization; o Outpatient Procedures; o Physical Therapy and other physical treatment modalities; o Surgery. o Prescription Drug Utilization • Provide service requests within the applicable time standards and provided medical advice as warranted. • All proposed, concurrent, and retrospective utilization review requests must be reviewed and a determination made within 3 working days from receipt of information, but not to exceed 15 calendar days from receipt of information, or less if set forth in URAC guidelines. • Provide certified, non-certified, and part-certified determinations using a uniform format as specified by DDOL. • Use “like specialists” to review and issue non-certification determinations. The “like specialists” will meet the following criteria, which is slightly different from URAC’s WCUM-14 standard: a. Are appropriate health professionals; b. Are qualified, as determined by the medical director or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review; c. Hold a current and valid professional license to practice in the contiguous United States: i. In the same licensure category as the ordering provider or ii. In the same licensure category as the treating provider
