January 16, 2026 | SIBTF.org — The California Division of Workers’ Compensation (DWC) has released its completed Utilization Review (UR) investigation results for claims administrators audited in 2025, offering a clearer view into how insurers and third-party administrators are performing under state-mandated medical review standards.
The results, published by the DWC Audit and Enforcement Unit, stem from profile audit reviews conducted once every five years. These audits evaluate whether claims administrators are complying with strict timelines and notice requirements governing medical treatment authorization decisions in California’s workers’ compensation system.
For stakeholders involved in complex benefit structures—including those intersecting with the Subsequent Injuries Benefits Trust Fund (SIBTF)—the findings provide critical insight into administrative reliability and systemic risk.
How Utilization Review Performance Is Measured
According to DWC, each claims administrator’s Utilization Review performance rating is calculated based solely on penalties cited under California Code of Regulations, title 8, section 9792.12(b). The rating reflects a composite score derived from three core compliance areas:
- Timeliness failures, where authorization decisions were not made or communicated within required deadlines
- Faulty notice content, including incomplete or inaccurate UR determination notices
- Failure to notify all required parties, such as injured workers or treating physicians
A performance rating of 85 percent or higher is considered passing. Scores below that threshold indicate compliance deficiencies that may trigger mandatory penalties.
How UR compliance affects injured workers and benefit determinations
Utilization Review plays a gatekeeping role in California workers’ compensation, determining whether proposed medical treatments are authorized, modified, or denied. When UR processes break down, treatment delays and disputes often follow—issues that can complicate permanent disability evaluations and, in some cases, downstream benefit eligibility.
For SIBTF-related cases, where injured workers often present with layered medical histories and prior disabilities, consistent and compliant UR practices are especially important. Audit results highlighting repeated failures can signal broader administrative weaknesses with real consequences for claim outcomes.
What claims administrators cannot avoid
The DWC emphasized that penalties under 8 CCR §9792.12(a) are mandatory and cannot be waived, though mitigation may apply depending on factors outlined in §9792.13. Other penalty provisions may be waived or reduced only under specific regulatory conditions.
This framework underscores the state’s continued focus on enforcement rather than voluntary compliance, particularly as medical authorization disputes remain a persistent source of litigation in California workers’ compensation.
Claims administrators, attorneys, and injured worker advocates can review the full 2025 Utilization Review audit results directly through the California Department of Industrial Relations.
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FAQs: DWC Utilization Review
What is a Utilization Review audit?
It is a DWC investigation assessing whether claims administrators comply with medical authorization rules, timelines, and notice requirements.
How often are UR audits conducted?
Profile audit reviews, including UR investigations, are conducted every five years by the DWC Audit and Enforcement Unit.
What is a passing Utilization Review performance score?
A score of 85 percent or higher is considered passing under California regulations.
Can penalties for UR violations be waived?
Some penalties may be mitigated or waived depending on the specific violation and the factors outlined in the regulations, but mandatory penalties under 8 CCR §9792.12(a) cannot be waived. This means that if a claims administrator is found to have violated certain core UR requirements—such as failing to make a timely determination or improperly denying authorization—the penalty is automatically required, even if the administrator shows good intent or corrective actions after the fact.