Notice Of Appeal Rights For A Utilization Review Denial {C-35A}

C-35A - NOTICE OF APPEAL RIGHTS FOR A UTILIZATION REVIEW DENIAL. For every UR denial, adjusters must pre-fill this form and send it with the Utilization Review Denial and Utilization Reviewer's Report to the employee, treating physician or other provider and any attorneys listed. Delays, incomplete or inaccurate information could result in a penalty referral. Employee/Physician/Attorney receiving this pre-filled notice means the requested treatment was reviewed and denied or modified by the carrier’s Utilization Review Organization and denied by the adjuster. You have the right to ask the Bureau of Workers’ Compensation to review the denial or modification by submitting this form. Follow the instructions on page 3. If no appeal is desired, you may keep this for your records. www.FormsWorkflow.com