Under what circumstances might a peer review be required in the claims process?

A peer review may be required in the claims process particularly when there are disputes about the necessity of medical treatment. This situation often arises when the insurance carrier or the employer questions whether the medical treatment being sought is appropriate and necessary for the employee’s injury. A peer review involves having experts in the field review the medical records and treatment plans to provide an objective opinion on whether the treatment aligns with industry standards and the specifics of the case. This process helps provide clarity and justification for both the employee and the employer or insurer regarding the proposed medical care.

In contrast, merely filing a claim does not inherently trigger a peer review; it is the specific situation around the treatment that prompts such a review. Similarly, reaching a settlement usually indicates that both parties have agreed on compensation and medical treatment, hence a peer review is typically not necessary at that stage. Additionally, the status of an injury being minor does not typically necessitate a peer review, as these reviews are more critical in complex cases where treatment and necessity are under scrutiny.