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Get the free Utilization Review Determination Face Sheet - dli.pa.gov

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UTILIZATION REVIEW DETERMINATION FACE SHEETDEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS COMPENSATION(To be completed by PRO)EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMERATE OF INJURYMMReview
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01
Gather all relevant medical records and documentation related to the patient's treatment.
02
Review the patient's medical history and current condition to determine the medical necessity of the treatment.
03
Complete the utilization review determination face form with accurate and detailed information.
04
Submit the form to the appropriate review entity for evaluation and decision.
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Follow up with the review entity as needed to provide additional information or clarify any questions.

Who needs utilization review determination face?

01
Healthcare providers
02
Insurance companies
03
Patients seeking approval for medical treatment
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Utilization review determination face is a form used to request a determination on the medical necessity of a proposed treatment or service.
Healthcare providers, insurance companies, and employers may be required to file utilization review determination face depending on the situation.
Utilization review determination face should be filled out with all necessary information about the proposed treatment or service, as well as any supporting documentation.
The purpose of utilization review determination face is to ensure that medical treatments and services are necessary and appropriate for the patient.
Information such as patient demographics, medical history, proposed treatment or service, and any relevant medical records must be reported on utilization review determination face.
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