UR PENALTIES

Penalties Pursuant to UR Enforcement Regulations



· $50,000: Failure to establish a UR plan

· $50,000: Failure to have medical director

· $25,000: Decision outside of scope of practice

· $25,000: Non-physician delays, denies, modifies treatment request

· $15,000: Untimely response to expedited request

· $10,000: Failure to discuss concurrent treatment with the treating physician

· $10,000: Failure to file plan or letter

· $ 5,000: Failure to include elements in plan

· $ 5,000: Failure to file modified plan after material modification within 30 days

· $ 5, 000: Denying treatment because the condition is not in the Medical Treatment Utilization Schedule

· $ 2,000: Failure to respond, non-expedited, concurrent

· $ 1,000: Failure to respond, non-expedited, prospective review

· $ 1,000: No documentation of amended request

· $500: Failure to respond to retrospective request

· $100: Failure to disclose UR criteria or guideline to public