Utilization Review




Argus coordinates utilization review (UR) as a quality assurance measure and a cost containment process. A comprehensive utilization review program for pre-authorization of medical services is essential to any claims management program as a means of preventing unnecessary medical expenses. Argus believes pre- authorization can be a vital tool to the claims professional. Preauthorization directs the treatment plan into a productive mode and protects the injured worker by helping to avoid unnecessary and counterproductive treatment measures.

Our preauthorization services encompass prospective, concurrent and voluntary preauthorization services. The direct interaction of our medical director and certified independent physician advisors helps reduce the overall costs of unnecessary treatments.


Utilization Review

Retrospective Utilization Review (Peer Review)


Argus offers several types of peer reviews including:


  • Physician Bill Review
  • Pharmacy Medical Necessity Review
  • Physician Peer Review
  • Chiropractic Peer Review
  • Impairment Rating Review


A Peer Review addresses a larger question of medical necessity or causal relatedness than does the physician bill review. A peer review looks at a larger portion of care being provided and issues a medical decision as to the relatedness or necessity of an entire course of treatment. The review can address specific questions as outlined by the adjuster. Reviews are matched by specialty of the treatment being reviewed and all Argus review physicians provide a signed, written review decision.


DWC-32 Review


House Bill 2600 in Texas opened new doors of communication for the carrier with designated doctors. A request from an insurance carrier for a Required Medical Examination on an issue involving an Impairment Rating or attainment of maximum medical improvement is to be performed by a Designated Doctor. Argus can assist in the coordination of this review. If needed, Argus can provide a peer review to address the medical necessity or impairment rating issues to determine if there is value in a Designated Doctor Examination at this time. If a designated doctor examination is indicated, Argus will complete the DWC 32 form and submit it to DWC. Once the carrier is notified of DWC’s approval, Argus will coordinate the setting of the appointment and get any medical documentation, including any peer reviews, to the Designated Doctor.


Argus coordinates Required Medical Evaluations, Second Opinion Examinations and Designated Doctor Examinations when needed; obtaining all necessary medical records and films required by the examining physician.


Impairment Rating Review


Argus’ impairment rating reviews control claims costs by ensuring that the final assessment of the impairment is accurately calculated. More than 75% of the impairment ratings Argus receives for review are calculated incorrectly due to dated, improper or inappropriate use of the AMA guidelines for calculations. Argus provides timely and accurate review of impairment rating calculations that allows the claims professional to make more objective decisions as to the need for a dispute.


Pharmacy Medical Necessity Review


If needed, Argus can provide a physician opinion in response to a statement of medical necessity submitted by a prescribing physician. The Argus bill review staff requests these statements when deemed appropriate. Though the nurse auditor provides the first level of review, Argus physicians are available to provide a written opinion should the prescribing physician appeal an audit denial based on the statement of medical necessity.