If a letter about your medical care mentions utilization review, medical necessity, or guidelines, a practical first step is to ask the adjuster or claim administrator, in writing, for a copy of the written decision and to keep it with your claim records. Reading the actual decision—rather than relying on a phone summary—helps you see who reviewed the request, what care was reviewed, and what criteria were cited.
Key takeaways
- The Board recognizes the URAC Workers’ Compensation Management 2008 guidelines, the Official Disability Guidelines (ODG), and the ACOEM guidelines.
- A guideline recommendation is not conclusive evidence for a Single Hearing Member or the Full Board.
- The Board’s employee guidance says that in Indiana the employer directs medical care.
- The Board’s informal dispute process is initiated by filing a completed Request for Assistance, State Form 45442.
- Disputes not resolved informally may move forward only if an Application for Adjustment of Claim, State Form 29109, is filed.
- For prescription drugs listed as “N” drugs in the formulary, the Board describes a separate review procedure.
What utilization review means in an Indiana workers’ comp claim
Under 631 IAC 1-1-32(11)[1], the Board’s paragraph headed “Utilization review” is about evidence: which guidelines the Board recognizes and how much weight their recommendations carry. The same paragraph appears within 631 IAC 1-1-32, a rule titled “Medical provider fee claims.” Neither that paragraph nor the rule’s definitions section defines “utilization review.”
Since the rule does not define the term, read closely any letter that uses it. Look for who performed the review, what specific care was reviewed, what records the reviewer looked at, and what guideline or criteria the letter cites. Those details matter more than the label.
A utilization-review letter should also not be confused with an independent medical examination. The Board’s informal-disputes page separately describes an independent medical examination (IME) process that applies when an employee disagrees with a carrier’s proposed termination of benefits. The employee must give written notice of disagreement to the Board and the employer within seven days of receiving the notice of intent to terminate benefits. If the Board determines the disagreement was timely and an examination is appropriate, it sends letters to the parties, the claimant has twenty-one days to respond, and after timely responses the Board sets and schedules the independent medical examination. If you receive a notice like that, read it carefully and note the date you received it.
How Indiana treats utilization-review recommendations
The rule recognizes three named sets of guidelines: the Utilization Review Accreditation Commission’s (URAC) Workers’ Compensation Management 2008 guidelines, the Official Disability Guidelines (ODG), and the American College of Occupational and Environmental Medicine (ACOEM) guidelines.
The rule says recommendations from these and other reputable sources may be offered as one form of evidence regarding appropriate medical care, but they will not be considered conclusive evidence by the Single Hearing Member or the Full Board. Put simply, a guideline-based recommendation can be part of the evidence in a dispute, but the rule says it does not settle the question by itself.
The larger medical-care context matters too. The Board’s employee guidance[2] states that in Indiana the employer directs medical care, and that if you do not feel you are receiving adequate medical care, you may file an Application for Adjustment of Claim with the Board.
You can read more about who chooses the doctor in an Indiana workers’ compensation claim and the firm’s broader Fort Wayne workers’ compensation practice.
What to request when utilization review affects treatment
The table below is a practical organizing checklist. It is not a statement that every item must be provided to you in every case; whether a particular document must be produced can depend on the stage of the dispute.
| Document or information | Question to answer |
|---|---|
| Written decision or denial | What exact reason was given? |
| Reviewer’s report, if one exists | What issue did the reviewer evaluate? |
| Records listed as reviewed | Was important information left out? |
| Your doctor’s request | What care was actually requested? |
| Guideline or criteria cited | Which source and version were used? |
| Claim correspondence | Who received notice, and when? |
Keep the documents together with your injury report, appointment notes, work restrictions, and messages. Our Indiana workers’ compensation recordkeeping checklist provides a broader way to organize a claim file.
As a practical step, you can let your doctor’s office know about the decision and ask whether they plan to respond or send additional records. Please do not change or stop your medical care based on a blog post; talk with your doctor about any questions regarding your care.
What can happen after a treatment denial
The Board’s informal dispute process[3] is initiated by filing a completed Request for Assistance, State Form 45442, with the Board. The Board says submitting the form authorizes its Case Coordinators to conduct an inquiry or investigation in an attempt to bring the claim to a resolution. The issues the Board lists as commonly encountered in this process include premature termination of medical and disability benefits and unpaid medical bills.
If the informal response is not favorable and the requesting party wishes to appeal it, the Board says the only legal remedy is the formal hearing process. The Board’s disputed-claims guidance[4] says a dispute not resolved informally may move forward only if an Application for Adjustment of Claim, State Form 29109, is filed, and the case is then assigned to a Single Hearing Member.
The appropriate route depends on the precise dispute and the status of the claim. You can review the firm’s guides to an Indiana Request for Assistance and an Application for Adjustment of Claim.
A dispute over medical care can involve medical records, Board procedure, and time limits that depend on the facts. The Board’s employee guidance says the Board always recommends consulting an attorney if you are contemplating disputing your claim.
Utilization review for certain prescription disputes
The Board describes its formulary guidance[5] as neither law nor formal regulation, but as the agency’s informal guide to meeting the requirements of the law, and says the document will change from time to time. Keep that in mind when reading the summary below, and check the Board’s current page for updates.
The Board’s formulary guidance says a provider who wishes to prescribe a medication listed as an N drug must first contact the payer. If the payer does not approve the request, the Board says the payer must send it for review to an organization holding a current URAC Workers’ Compensation Utilization Management Certification or Workers’ Compensation Pharmacy Benefit Management Certification. The payer must convey the reviewer’s decision to the prescriber and the injured worker, preferably in writing, though e-mail is allowed.
The guidance also says an N-drug denial should not be issued based on a lack of information from the prescribing physician; instead, questions should be directed to the physician. According to the same guidance, appeals of N-drug denials may be made by petition to the appropriate Single Hearing Member in a disputed case and to the Chairman in non-litigated claims. The guidance ties this procedure to IC 22-3-3-4.7[6] and IC 22-3-7-17.6[7].
This N-drug procedure applies to requests for prescription drugs listed as N drugs; it is not a general procedure for every denial of medical care. If your dispute concerns a prescription, it may help to note the drug, the prescriber’s request, the stated denial reason, and the date you learned of the decision.
Frequently Asked Questions
Is utilization review a final decision in an Indiana workers’ comp case?
A utilization-review recommendation is not the final word under Indiana’s rule, which says such recommendations may be offered as one form of evidence but are not conclusive evidence for a Single Hearing Member or the Full Board.
Can I ask for the utilization-review report?
You can ask the adjuster or claim administrator, in writing, for the written decision and any report or criteria it relies on. Whether a particular document must be produced can depend on the stage of the dispute and the procedure that applies, so an attorney can help if a request is refused.
What if the reviewer did not receive important medical information?
As a practical step, tell your doctor’s office and the claim administrator what appears to be missing and ask how it can be supplied. For N-drug prescription requests, the Board’s formulary guidance says a denial should not be issued based on a lack of information from the prescribing physician and that questions should be directed to the physician.
How do I dispute a treatment denial?
The Board’s informal dispute process begins with a completed Request for Assistance, State Form 45442. Under the Board’s disputed-claims guidance, a dispute not resolved informally may move forward only if an Application for Adjustment of Claim, State Form 29109, is filed. The correct step depends on the type of denial and the status of the claim.
Sources
- Indiana Administrative Code, Title 631, Article 1 (Worker’s Compensation), including 631 IAC 1-1-32 (Medical provider fee claims), subsection (11) “Utilization review,” Indiana General Assembly. Accessed 2026-09-30. https://iar.iga.in.gov/latestArticle/631/1[1]
- 631 IAC 1-1-32, text as published by the Legal Information Institute, Cornell Law School. Accessed 2026-09-30. https://www.law.cornell.edu/regulations/indiana/631-IAC-1-1-32[8]
- Who Is Eligible (employee guidance), Worker’s Compensation Board of Indiana. Accessed 2026-09-30. https://www.in.gov/wcb/employees/who-is-eligible/[2]
- Informal Disputes, Worker’s Compensation Board of Indiana. Accessed 2026-09-30. https://www.in.gov/wcb/informal-disputes/[3]
- Disputed Claims, Worker’s Compensation Board of Indiana. Accessed 2026-09-30. https://www.in.gov/wcb/disputed-claims/[4]
- Indiana Worker’s Compensation Formulary, Worker’s Compensation Board of Indiana. Accessed 2026-09-30. https://www.in.gov/wcb/formulary/[5]
If medical care in your Indiana work-injury claim has been delayed or denied after a utilization review, you are welcome to contact Delventhal Law Office to talk about your situation. A consultation is free, and we can discuss the documents you have and the process that may apply.
This article is general information about Indiana law and is not legal advice. Reading it does not create an attorney-client relationship, and neither does contacting us.
