Navigating the 2026 UR Regulation Overhaul

From the Desk Of:

Scott M. Tilley, Esq.

President, Managing Attorney

Certified Specialist Workers' Compensation Law

The State Bar of California Board of Legal Specialization

Effective April 1, 2026, California implemented a significant overhaul of its Workers’ Compensation Utilization Review (UR) system. Driven by Senate Bill 1160 and Assembly Bill 1124, these updates represent the most substantial changes to the UR and penalty structure since its inception.

The primary objective is clear: to address complaints of excessive delays and ensure injured workers receive medically necessary treatment faster.

1. The End of the "Perfect" RFA

Under previous rules, the UR process only began upon receipt of a "completed" Request for Authorization (RFA). The new regulations eliminate these strict requirements. Now, claims administrators must act on any request received. Within five business days, they must either:

• Accept the request and comply with UR requirements.

• Return the request as "not complete," specifically identifying the reasons for return.

2. The 30-Day Prospective UR Exemption

To accelerate early-stage care, CCR 9792.9.7 now allows certain treatments within the first 30 days of an injury without prospective UR. To qualify:

• The treatment must be for an accepted body part or condition.

• Treatment must be consistent with the Medical Treatment Utilization Schedule (MTUS).

• The physician must concurrently submit a Doctor’s First Report (DFR) and an RFA.

Note: This exemption is NOT absolute. Services such as non-emergency surgery, home health care, psychological treatment, and most imaging still require prospective UR.

3. Accelerated Drug Formulary Timelines

Disputes regarding drugs listed on the MTUS formulary now move at an accelerated pace:

• Decisions: For non-exempt drugs on the MTUS list, UR decisions must be made within five business days, and this timeframe cannot be extended.

• Appeals: The deadline for an injured worker to file an Independent Medical Review (IMR) appeal for drug-only disputes is shortened from 30 days to 10 days.

4. Increased Oversight and "No-Waiver" Penalties

The Division of Workers' Compensation (DWC) has significantly increased its oversight. Key changes include:

• Mandatory Accreditation: All UR plans that modify or deny treatment must prove URAC accreditation.

• No Penalty Waivers: The DWC has eliminated the "performance rating" system that previously allowed penalty waivers for high scores. Every violation will now be penalized.

• Escalating Fines: Many flat fees have been replaced by daily or hourly penalties. For example, failure to timely communicate an expedited review decision can cost $250 per hour, up to $18,000.

Summary for Claims Administrators

This represents a paradigm shift. Compliance is no longer about a "passing score"; it is about meeting requirements for every single transaction. We recommend an immediate review of all UR and MPN protocols to avoid significant financial consequences.