What if the specific DME requested is the most expensive model, while a less expensive model is just as effective?
UR agents determine medical necessity and appropriateness of care. The issue of cost for DME is a determination the adjuster should make. 10. The UR agent cannot release UR info/medical documentation to a case manager, but can the UR agent releases information to the WC insurance adjuster/company. Does the case manager then have access to UR records? The statute allows for information to be shared within the WC system, i.e. adjuster to UR. Case management is an ancillary service provided by some managed care systems. As Circular Letter 274 states, ancillary services cannot be conducted under the UR regulations. UR records must have limited access and ensure confidentiality. The case manager may access UR information from the claims adjuster (we do not regulate adjusters). However, UR records must be separate and distinct from insurer functions. The case manager cannot directly access UR records.
