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CareReview's Approach to Workers' Compensation Review

Prospective, concurrent, and retrospective review, visualized.

CareReview's Approach to Workers' Compensation Review

Prospective, concurrent, and retrospective review, visualized.

CareReview supports workers' compensation payers and TPAs with specialty-matched physician review across every stage of a claim — prospective, concurrent, and retrospective — each evaluated against ODG, ACOEM, and MTUS guidelines, with a written, evidence-based rationale behind every certified or non-certified determination. When a determination is disputed, jurisdiction-specific appeal pathways — including Independent Review Organization (IRO) or Independent Medical Review (IMR) — provide the next step.

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Workers' Compensation Review Process. Three review types feed into a central Workers' Compensation Review, which produces a Determination. Prospective review evaluates treatment requests against ODG, ACOEM and MTUS guidelines before care is delivered, often informally called precertification, escalating to a specialty-matched physician when criteria are not clearly met. Concurrent review evaluates ongoing treatment while care is being delivered, confirming continued medical necessity against the same criteria as care progresses. Retrospective review evaluates treatment and billing after care is delivered, applying the same guideline criteria used in prospective review to confirm medical necessity after the fact. Every determination — prospective, concurrent, or retrospective — comes with a written, evidence-based rationale: certified or non-certified.

This is the review process CareReview runs for workers' compensation clients, from prospective review through a determination documented well enough to hold up on appeal. See our full Workers' Compensation solution page for the complete scope, including peer review, pharmacy review, and IME coordination.

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