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Utilization Reviews (UR)

What is Utilization Review (UR)?

The utilization review process compares requests for medical services ("utilization") to treatment guidelines that are deemed appropriate for such services and includes the preparation of a recommendation based on that comparison. The Utilization Review Program applies only to claims that are adjudicated by the State Fund. The program applies to both physicians and facilities. L&I contracts with Qualis Health for Utilization Review. 

Goal

The utilization review process supports the agency's mission to purchase only proper and necessary care for injured workers.

What Requires Qualis Health Review

All inpatient hospitalizations

  • Exceptions
    • inpatient chemical dependency treatment and
    • sub-acute stays, such as skilled nursing facility, transitional care unit or other setting that is not an acute care stay

Selected outpatient surgical procedures

  • Procedures may be added or deleted due to code changes.
  • UR Simplification applies to most outpatient surgeries.
  • Some procedures/services may not require UR, but would still need to be authorized by claim managers.
  • Providers can enter the Billing Code ID in the Fee Schedule Lookup tool to determine current outpatient procedures requiring UR
    • If the Prior Authorization box indicates “Y-UR” providers must request a review through Qualis Health.

Physical Medicine:

Physical therapy, occupational therapy and work conditioning require UR after the 24th visit.

Advanced Imaging Studies

MRI studies of the spine, upper and lower extremities and brain MRI and CT studies for headaches require UR. UR requests for imaging require web access through OneHealthPort.com

Spinal Injections

All spinal injections require UR review. See medical treatment guidelines.

Criteria used for review

Qualis Health uses the Department's Medical Treatment Guidelines.

  • When there are no Department Medical Treatment Guidelines available, Qualis Health utilizes InterQual criteria.
  • Initial clinical review is conducted by a registered nurse or therapist
    • does not meet guidelines or criteria, referred for physician review
    • physician reviewer unable to recommend approval
      • requesting physician has the opportunity to discuss the case
  • Qualis Health recommendations are sent to the L&I claim managers.
    • The claim manager will review the information and recommendation made by Qualis Health and will then decide whether to authorize or deny the request.
    • The claim manager will issue the final determination and inform the requesting provider.

Non-initiated claims

Qualis Health will review requests for treatment or procedures on non-initiated claims in the same manner as initiated claims.

  • Physicians and facilities must follow the same UR process, however, L&I's determination will be delayed until the claim has been initiated and assigned to a claim manager.
  • Decisions to proceed with appropriate medical care should be based on the providers' best clinical judgment and not on the status of the request.

UR Simplification (Group A Provider)

Those providers with 100% UR approval recommendations when they performed 10 or more reviews during the one year review period may be eligible to become a Group A Provider.

Responsibility

The Office of the Medical Director (OMD):

  • manages the contract with the L&I UR vendor, and
  • monitor's their quality of reviews.

Qualis Health, L&I's contracted UR vendor:

  • Review cases against L&I's Medical Treatment Guidelines or InterQual criteria, and
  • Recommend a course of action to the L&I Claim Manager.

Utilization Review Definitions

Additional resources for NEW Providers – not currently doing business with Qualis.

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