Workers Compensation Utilization Review Services

The Vendor is required to provide utilization review services (UR), and peer review (PR) the city anticipates selecting one firm to perform these services.
- Provide UR/PR services to ensure that treatment requests from medical providers are appropriate for patient medical conditions, follow evidence-based guidelines, and follow all legal and statutory requirements and regulations as identified by the department.
- Provide trained healthcare professionals (nurses and physicians) experienced in the evaluation of treatment plans and the validation of medical necessity for workers’ compensation claims utilizing guidelines from the college and the treatment, and/or others as appropriate.
- Consultant shall have the capability of sending any and all appropriate advice letters to the injured worker, claims staff, legal counsel, and the provider making the request for treatment.
- These letters may include delay of treatment, requests for further information and or denial of treatment in accordance with current laws and regulations. 
- Consultant shall electronically provide copies of these letters to the claims examiner at the time of issuance.
- Consultant shall be responsible for ensuring that the COR requests for UR/PR services can be electronically submitted and received.
- provide annual comprehensive reporting on provider treatment patterns and a physician review scorecard.
- Provide monthly UR/PR reports that contain the following data elements:
•    Claim number
•    Claimant name
•    Claims examiner
•    Provider name
•    Injury dates
•    Referral dates
•    Referral lag (injury date to referral date)
•    Turnaround time for all decisions and notification elements for which there are deadlines under state statutes
•    Case duration
•    Itemized fees with descriptions
•    Itemized savings with descriptions
•    Categorically separated feed (i.e. UR Fees, PR fees)
•    Outcome descriptions
- Provide on-site training for all workers’ compensation (WC) staff as needed including but not limited to, how to interface with the Consultant’s, utilization review legal requirements, and other programmatic updates/changes.

- Contract Period/Term: 2 years
- Questions/Inquires Deadline: September 11, 2025