Form WC131 "Request for Utilization Review" - Colorado

What Is Form WC131?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC131 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC131 "Request for Utilization Review" - Colorado

110 times
Rate (4.7 / 5) 7 votes
COLORADO DIVISION OF WORKERS' COMPENSATION
MEDICAL UTILIZATION REVIEW PROGRAM
REQUEST FOR UTILIZATION REVIEW
(Pursuant to §8-43-501, C.R.S.)
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION. All information and addresses must be verified as current
and accurate.
1.
Date of Request _______________________
2.
WC Number __________________________
Date of Injury ____________________
WC Number __________________________
Date of Injury ____________________
3.
Claimant's Name _____________________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
Attorney's Name ______________________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
4.
Party Requesting Review _______________________________________________________________________
Primary Contact at Party's Office _________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
Attorney's Name _____________________________________________________________________________
Address ___________________________________________________Tel No. ___________________________
City ______________________________________________________State _____________ Zip ____________
5.
Authorized Physician to be Reviewed _______________________________________________________________
Practice/Association Name ______________________________________________________________________
Address ___________________________________________________Tel No. ___________________________
City ______________________________________________________State _____________ Zip ____________
6.
Attach copies of all admissions and/or orders filed or entered in this case.
My signature certifies the following a) all names and addresses on this form have been verified as current and accurate; b)
copies of all admissions and/or orders filed or entered in this case are attached; c) seven identical copies of associated medical
material are being submitted for review; d) all items listed on the table of contents are in each copy of the medical material; and
e) the initial processing fee is attached.
_________________________________________
______________________________________________
Print Name of Requester
Signature of Requester
COPY THIS FORM OR REPRODUCE EXACTLY IN APPEARANCE AND CONTENT
S E E I N S T R U C T I O N S O N B A C K
WC131 Rev 05/16
Page 1 of 2
COLORADO DIVISION OF WORKERS' COMPENSATION
MEDICAL UTILIZATION REVIEW PROGRAM
REQUEST FOR UTILIZATION REVIEW
(Pursuant to §8-43-501, C.R.S.)
PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION. All information and addresses must be verified as current
and accurate.
1.
Date of Request _______________________
2.
WC Number __________________________
Date of Injury ____________________
WC Number __________________________
Date of Injury ____________________
3.
Claimant's Name _____________________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
Attorney's Name ______________________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
4.
Party Requesting Review _______________________________________________________________________
Primary Contact at Party's Office _________________________________________________________________
Address ___________________________________________________Tel No ___________________________
City ______________________________________________________State _____________ Zip ____________
Attorney's Name _____________________________________________________________________________
Address ___________________________________________________Tel No. ___________________________
City ______________________________________________________State _____________ Zip ____________
5.
Authorized Physician to be Reviewed _______________________________________________________________
Practice/Association Name ______________________________________________________________________
Address ___________________________________________________Tel No. ___________________________
City ______________________________________________________State _____________ Zip ____________
6.
Attach copies of all admissions and/or orders filed or entered in this case.
My signature certifies the following a) all names and addresses on this form have been verified as current and accurate; b)
copies of all admissions and/or orders filed or entered in this case are attached; c) seven identical copies of associated medical
material are being submitted for review; d) all items listed on the table of contents are in each copy of the medical material; and
e) the initial processing fee is attached.
_________________________________________
______________________________________________
Print Name of Requester
Signature of Requester
COPY THIS FORM OR REPRODUCE EXACTLY IN APPEARANCE AND CONTENT
S E E I N S T R U C T I O N S O N B A C K
WC131 Rev 05/16
Page 1 of 2
REQUIRED CONTENT, PRESENTATION AND BINDING METHOD
FOR ALL MATERIALS SUBMITTED FOR UTILIZATION REVIEW
In accordance with 8-43-501, C.R.S, and Colorado Workers' Compensation Rules of Procedure, 7 CCR 1101-3, Rule 10, all
information and medical records submitted to the Division for a Medical Utilization Review must represent all of the facts of
this case.
INFORMATION PACKAGE - REQUIRED CONTENT
Completed and signed Request for Utilization Review Form.
Copies of all admissions and/or orders filed or entered in this case.
A list containing the full names and medical degrees of all providers, including the provider under review, other
treating providers, and individuals who performed or are considered as referrals, consultations, IME's and/or second
opinions.
The initial fee payment of $1,250.00 must be included in the "Information Package", made payable to the Division of
Worker's Compensation, Medical Utilization Review, and reference the claimant's name. Deposit of the fee does not
constitute acceptance of the case for utilization review.
MEDICAL RECORDS PACKAGE - REQUIRED CONTENT
1. Case Report - prepared, signed and dated by a licensed medical professional. This report shall be dated within thirty
(30) days of the date of filing with the Division. The case report shall be limited to the following:
a. Name, discipline of care and specialty of the Provider under review; date the provider first treated the claimant.
b. Claimant's standard demographic information (age, sex, marital status, etc.).
c. Claimant's employer and occupation/job title, date(s) of claimant's work-related injury/exposure.
d. Date of initial treatment, a brief chronological history of treatment to the present date, and any significant
contributing factors which may have had a direct effect on the length of treatment (e.g., diabetes).
e. A brief statement from the medical professional after review of the medical records in support of utilization review.
2. Table of Contents
Section 1.
A copy of the Employer's First Report of Injury and/or the Worker's Claim for Compensation form.
Section 2.
All reports, notes, etc., from provider being reviewed as submitted to the requesting party.
Section 3.
All reports, notes, etc., of other treating providers as submitted to the requesting party.
Section 4.
All reports resulting from referrals, consultations, IME's and second opinions as submitted to the
requesting party.
Section 5.
All diagnostic test results as submitted to the requesting party.
Section 6.
All medical management reports as submitted to the requesting party.
Section 7.
All hospital/clinic records related to the injury as submitted to the requesting party.
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 presented in chronological order.
REQUIRED PRESENTATION AND BINDING METHOD FOR ALL SUBMITTED MATERIALS
♦ INFORMATION PACKAGE - SUBMIT ONE COPY ONLY -- staple in upper-left-hand corner.
♦ MEDICAL RECORDS PACKAGE - SUBMIT SEVEN (7) COPIES
a.
All submitted material must be presented in seven (7) identical copies, two-hole punched at the top center of
each page and securely fastened.
b.
Put a blank sheet of paper on the front and back of each copy of the submitted material (any color except black
or a very dark color).
c.
If tabs are used for the sections, they must be positioned to the right side of the document.
Mail or Deliver to:
Division of Workers' Compensation
Medical Utilization Review Program
633 17th St., Suite 400
Denver, CO 80202-3626
303.318.8767
WC131 Rev 05/16
Page 2 of 2
Page of 2