REQUIRED CONTENT, PRESENTATION AND BINDING METHOD

FOR ALL MATERIALS SUBMITTED FOR UTILIZATION REVIEW

In accordance with 19 Del.C. §2322 F(j) and the regulations adopted pursuant thereto, all information and medical records submitted to the Department of Labor, Office of Workers’ Compensation must represent all of the facts of this case.

INFORMATION PACKAGE · REQUIRED CONTENT

• Completed and signed Request for Utilization Review Form.
• If applicable, a list containing 1) names, addresses, etc. of the health care facilities impacted by this review; and 2) additional health care providers under review.
• Proof of date of issuance of claim denial (so the Department of Labor is able to verify that Utilization Review was requested within 15 days of the date of the claim denial).

MEDICAL RECORDS PACKAGE· REQUIRED CONTENT

Section 1. All reports, notes, etc., from provider being reviewed from the date of injury or the two

Section 2. All reports, notes, etc., of other treating providers from the date of injury or the one

Section 3. All diagnostic test results from the date of injury or the two (2) year period

NOTE  Do not include copies of any billing statements or comments/instructions directed to the Utilization Review panel. All material must be presented in identified sections; each section’s content must be presented in chronological order.

REQUIRED PRESENTATION AND BINDING METHOD FOR ALL SUBMITTED MATERIALS

a. All submitted material must be presented in two (2) identical bound copies.

b. If tabs are used for the sections, they must be positioned to the right side of the document.

Mail or Deliver to:

Department of Labor
Office of Workers’ Compensation
4425 N. Market St.
Wilmington, DE 19802
302-­761-­8200