In Pennsylvania workers' compensation, an employee, employer or insurer can ask for utilization review of a provider's treatment, and the assigned utilization review organization (URO) issues its decision with this face sheet. It names the provider under review and the reviewer, and states whether the care was reasonable and necessary in full, in part or not at all. Treating clinicians see it because their care is the subject.
The URO completes the whole face sheet, signed by its authorized representative and naming a reviewer with professional licensure and specialty. The treating provider does not fill it; as the provider under review, that clinician supplies records.
Download the current version from the source each time; forms change without notice.
Utilization Review Determination Face Sheet
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The notice on the face sheet says a party who disagrees may file a Petition for Review of Utilization Review Determination before a workers' compensation judge, filed with the Bureau within thirty days of receiving the URO's determination. A copy must go to the employee, insurer, employer and health care provider.
The face sheet lists several reasons: the request was withdrawn, the requestor did not meet the Act's definition of health care provider, or the request named the wrong provider under review under 34 Pa. Code 127.452(d) or (e). In those cases the URO checks the matching box instead of deciding necessity.