The Intelligent Insurance Solution

Utilization Review Procedure

Utilization Review/Pre-Certification Procedures For All Participants in the Medical Care Plan

Pre-Certification is Required on the Following:

  • Physical/Occupational Therapy – once total visits exceed WCC Medical Protocols for specified body part as outlined in WCC Payor/Provider Guidelines
  • Chiropractic Services – once total visits exceed WCC Medical Protocols for specified body part as outlined in WCC Payor/Provider Guidelines
  • Surgery (Inpatient/Outpatient) – two weeks prior to scheduled surgery date
  • Hospital Admissions – Scheduled and Emergency beyond the first 24 hrs
  • Pain Management – Prior to any invasive procedure rendered within a surgical facility

Re-Certification is Required on the Following:

  • Physical/Occupational Therapy – before services continue either for an extension of the end date or for additional services
  • Chiropractic Services – before services continue either for an extension of the end date or for additional services
  • Pain Management – before services continue for an extension of the end date or for additional services 

In order to be able to process the request for service, please submit the following:

  1. Physician Orders
  2. ICD9 Code(s)
  3. CPT Code(s)
  4. Start Date/Admit Date
  5. Frequency and Duration of Treatments/Anticipated Length of Stay
  6. Therapy/Chiro notes after Initial Evaluation or on re-certification

Please remember that a certification has two (2) components, the number of visits approved and the start and end date of the approval. If treatment needs to extend beyond the end date, an extension of the end date must be requested on or prior to that date.