WC131 Rev 05/16 Page 2 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
