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.

Inpatient & Outpatient Requests

For inpatient and selected outpatient reviews

Qualis Health provides Web-based utilization review via iEXCHANGE which allows providers to:

• submit and review request status
• complete questionnaires that can impact the request status
• view updates
• provide additional information, if requested
• be assured of secure access, and
• print reviews and authorization requests for patients and files

Before you request Utilization Review

1. Verify the claim status.
2. Verify that the condition being treated is accepted under the claim. If treatment is not for the accepted condition, the department will ask you to verify how the condition and recommended treatment is related to the original injury.
3. If a claim has not been submitted, complete a Report of Accident (ROA) form.
   • Fax all ROAs to: 800-941-2976.
   • You can still request utilization review; however, the request cannot be processed until the claim is initiated.

To verify the claim information:

1. Call the Interactive Voice Response system (IVR) – Automated Claim Information
   • 800-831-5227 Monday – Friday, 6 a.m. to 7 p.m. Pacific time
   • Have your provider account number ready when you call.
2. Login to the Claim & Account Center (CAC) if you are the attending physician, IME, concurrent care or vocational provider

Request a Review

1. Refer to L&I's Medical Treatment Guidelines for information on what specific clinical information is required for selected procedures.
2. Complete and fax one of the following:
   • Surgical Request for Review form and attach your clinical information, or
   • Login to iEXCHANGE®, request a review, then fax your clinical information.
3. Fax your information to Qualis Health at:
   • 1-877-665-0383
   • 206-366-3378
4. For questions call Qualis Health at:
   • 1-877-541-2894
   • 206-366-3360

What to expect next

1. When Qualis Health receives a request for a prospective review (see "Definitions" section) with all the necessary clinical information,
   • a "notification number" will be assigned and
   • The case is forwarded to a nurse for review.
     • The nurse will compare the clinical information to either the Department’s Medical Treatment Guidelines or other criteria.
     • If the clinical information supplied with the request does not meet the guidelines and/or the criteria, the Qualis review nurse will refer the request to a physician consultant for review.
     • If the physician consultant can not recommend approval, an offer to discuss the clinical information will be made to the requesting physician. Based on available information, the physician consultant will make a recommendation.
       • If the requesting physician disagrees with the recommendation for denial, a re-review may be requested. Re-review is performed by matched Specialty physicians.
2. Qualis Health will notify the provider
   • When they have completed a review,
   • Provide the notification number, and
   • Who to contact at the department for authorization.
3. After authorization by the claim manager the “notification number” will become the Department's Prior Authorization number.
4. Qualis Health will perform a concurrent review (see "Definitions" section)
   • if continued hospitalization is required beyond the initial or subsequent recommended length of stay
5. Qualis Health will perform a retrospective review (see "Definitions" section) in the same manner as a prospective review, only the services will have already been provided.

To avoid delays in patient care, call Qualis back quickly on peer-to-peer calls from their nurses or consulting physicians.

Additions or changes to the CPT© codes or dates of service

For all inpatient reviews or outpatient procedures that need corrections or additions to CPT codes or dates of service contact:

• Qualis Health at 800-541-2894
• Fax 1-877-665-0383

Please include:

• Coversheet with the additions or changes to the CPT© codes or DOS being requested.
• Copy of the operative report.

Utilization Review Definitions

Advanced Imaging Requests

The department requires requesting providers to use web based Advanced Imaging Review. L&I contracts with Qualis Health for Advanced Imaging UR. Qualis Health and OneHealthPort have partnered to arrange streamlined, web-based access to iEXCHANGE®.

OneHealthPort provides online services for healthcare professionals and includes access to multiple health plan sites in Washington State.

Benefits to registering through OneHealthPort include:

• One secure logon identification
• Streamlined, web-based access to iEXCHANGE®.
• Includes access to multiple health plan sites in Washington State

Request a review for Advanced Imaging

Providers should take the following steps to acquire authorization and ensure that medical necessity has been met for:

• MRI of the spine
• Upper extremity
• Lower extremity
• Brain MRI or CT of the head due to headache

1. Refer to L&I's Evidence-based Imaging Guidelines for information on what specific clinical information is required for selected procedures. Checklists were developed from the Evidence-based Imaging Guidelines for requesting providers.
2. Requesting providers may complete the following iEXCHANGE® Imaging Questionnaires in advance to assist staff with submitting their requests through iEXCHANGE®.

• Questionnaires are posted on the Qualis site for the following selected procedures:
  • Cervical Spine
  • Headache
  • Lower Extremity
  • Lumbar Spine
  • Thoracic Spine
  • Upper Extremity

3. If you already have access to iEXCHANGE® through Qualis or OneHealthPort skip to Step 5, if not proceed with Step 4.
4. If you do not yet have access to iEXCHANGE® through Qualis or OneHealthPort.
   • You may temporarily complete the Advanced Imaging Request for Review form and fax your request along with the completed checklist to Qualis at:
     

     Fax:	800-541-2894
     Phone:	800-541-2894, or
     Mail:	P O Box 33400 Seattle, WA 98133-0400

   • Make sure you complete the required registration through Qualis Health. Temporarily faxing your request is limited on a short term basis, pending completion of the registration process.

5. If you already have an existing iEXCHANGE® account login through OneHealthPort.
6. Qualis Health provided an iEXCHANGE® Training Manual for L&I’s advanced imaging. We recommend you following these instructions until you become familiar with the process.
7. Complete the appropriate questionnaire. Make sure you include your contact information (name and phone number) in the ‘Communication’ box before you click ‘Next step’. This information is necessary so department staff can call you with their authorization decision.
8. Preview your request and make any appropriate changes.
9. Complete the ‘Additional Authorization Questionnaire’ before you submit your request. Upon completion, click ‘Submit questionnaire’.
10. Review your request, if no additional changes are necessary click ‘Submit’.
11. A confirmation page will appear. We encourage you to copy this information for tracking. You may click on the “Print friendly version” to make a copy for your records.

• The Case ID number confirms your request was completed and received by Qualis.
• The Reference Number will become your Pre-Authorization (PA) number following L&I’s decision.
• Print or otherwise document the PA number for reference when contacting the department about the final determination.
• A recommendation or status of “approve” or “pend” will post.  These recommendations are electronically transmitted to L&I within 24 hours.
  • Pend results will be reviewed by Qualis Health and may result in either a recommendation to approve or deny.
  • Approve results will be reviewed by L&I to make the final allowance decision after verifying that the procedure is related to an accepted on-the-job injury or illness.

12. Department staff will review requests and will enter the authorization or denial into the claim system based on claimant eligibility and validity.
13. Department staff will notify the requesting provider of authorization decision.

• Contact name and phone number must be provided in the “Communications" box on the web-based review request in order for the department to notify you.
• Final notification by L&I should occur within 24-48 hours.

14. The submitting provider will receive a call. If they cannot be reached by phone a letter will be sent.

Claims that are new or that have not been entered into the system may take longer to generate an authorization decision.  Department staff will contact you with the status of the claim and the request.

Providers with access to the Claim and Accounts Center will be able to view authorization status for imaging requests.

Background - Why are we doing this?

The Washington Legislature passed a law in 2009 (ESHB 2105/ Chapter 258) that directed the State to convene an Advanced Imaging Management Work Group.  State agencies were directed to implement the Work Group recommendations.

More information is available here

These guidelines apply to State Fund, Self Insured and Crime Victims programs and they require prior authorization.

State Fund UR requirements do not apply to Crime Victims and Self Insured programs.

For Crime Victims Claims

To request authorization for advanced imaging please contact the Crime Victims’ Compensation Program’s claim manager by:

• Phone: 800-762-3716 (toll free)
• Fax: 360-902-5333

Additional information is available at: www.CrimeVictims.Lni.wa.gov

For Self-Insured Claims

Contact the self-insured employer (SIE) or the third party administrator (TPA) to request authorization.

Pilot Program for Expedited Review

L&I will pilot an expedited review program for advanced imaging studies with organizations and all of it’s affiliated providers that:

1. Have complete access to the organization’s electronic health record system.
2. Use evidence-based advanced imaging criteria/check-lists that are substantially equivalent to those implemented by the State.
3. Use compulsory order entry for all advanced imaging studies procedures prioritized by the State, and

• Have demonstrated that an automated ‘hard stop’ (i.e., denial of authorization) will occur for requests not meeting the priority criteria, OR
• Absent an automated ‘hard stop’ is able to demonstrate maintenance of appropriate utilization (e.g., data showing ratios comparable to expected utilization, consistent with organizations using hard stops).

4. Demonstrate use of system with at least 6 months of data showing expected reductions in inappropriate utilization or maintenance of appropriate utilization of advanced imaging for all priority areas.
5. Share utilization data for priority imaging with the State on a quarterly basis.
6. Have the capacity to self-audit to verify ongoing compliance with the State or equivalent criteria for all priority areas.

Expedited review requires web-based access to One Health Port and completion of an abbreviated form in iEXCHANGE® for each imaging request. For more information about this program please contact Diane Walker, Occupational Nurse Consultant, at 360-902-5182, or Diane.Walker@lni.wa.gov.

 

Physical & Occupational Therapy UR Requests

Physical (PT) and occupational therapy (OT) visits accumulate separately.

Visit counts are the total number of visits per claim. New referrals, restart of therapy following surgery, or treatment of new conditions on the same claim do not start again at visit 1.

If Work Conditioning is provided by both PT and OT and greater than 24 visits have previously occurred for either therapy discipline, utilization review is required. If Work Conditioning is denied, L&I will allow up to 12 visits for the discipline that hasn't reached 12 visits.

Request a review from Qualis Health (QH):

1. For outpatient physical/occupational therapy beyond 24 visits, the therapy provider may:

• Use iEXCHANGE® - QH's secure internet application, OR
• Send Qualis a Physical Medicine Request for Review form, AND Physical/Occupational Therapy Questionnaire (forms are on the Qualis web site), OR
• Call 1-800-541-2894 or 206-366-3360

2. For work conditioning, send Qualis:

• A Physical Medicine Request for Review form, AND
• The Work Conditioning Questionnaire, AND the attending physician’s:
  • Request for work conditioning, OR
  • A signature agreeing with the therapist's recommendation
  AND,
  • Evaluation or Progress Report, including:
    • Performance based physical capacities evaluation, OR
    • Clinic progress reports (latest and 1 prior report), OR
    • Work conditioning evaluation.

Note: QH may request additional documentation, if it’s not already on file with L&I’s claim record. A separate records release is not required. Documentation will still need to be sent to L&I.

3. QH will notify the therapy provider that a review is in process and provide a 10 digit reference number.
4. A QH therapist reviews the request and compares clinical information to InterQual®. If InterQual® criteria:

• Are met, the QH therapist makes a recommendation for approval.
• Are not met, the request is referred to a physician reviewer. QH will verbally notify the therapy provider of a potential denial.

5. The QH physician reviews the clinical information.

• If the QH physician is able to support the request, the QH physician will recommend approval.
• If the QH physician is not able to support the request:
  • The QH physician will contact the prescribing or attending physician.
  • The prescribing or attending physician has the opportunity to provide additional information to the QH physician to support their request.
  • The QH physician makes a recommendation to approve or deny services.

6. QH sends a report with a recommendation to L&I.
7. The L&I claim manager reviews the recommendation and makes a decision to authorize or deny services.

• The claim manager communicates the decision to the provider by phone and/or letter.
• If authorized, the 10 digit reference number becomes the prior authorization number.

8. If the prescribing physician or any party disagrees with the recommendation, they may request that QH provide a peer-matched MD review of a denial or partial approval determination.
9. QH will perform the re-review and submit recommendations to L&I.
10. The L&I claim manager will review the recommendations and make a decision to authorize or deny services.
11. The Office of Medical Director (OMD) will ‘reconsider’ a denial or partial approval determination only after a re-review has taken place at Qualis.

• All relevant claims documentation will be reviewed. Claim manager will be notified of the decision.

Utilization Review Definitions

UR Simplification (Group A Providers)

Reduced UR requirement for providers who had consistent UR approval recommendations does not increase utilization of unauthorized services.

PROVIDERS - CRITERIA TO DETERMINE STATUS					CASES ALLOWED
NEW	CONTINUED	WARNING	REMOVAL		PROPOSED CHANGES
Provider must have submitted at least 10 UR requests during the evaluation period. Requests may be any combination of IP and/or OP procedures. Providers who have only submitted IP requests will not be considered. Provider must have 100% on non-Group A procedural requests approved. Review period will be based on previous 12 FULL months of data (October through September). Certain procedures are exempt from Group A program and will require a full UR review. (Refer to cases allowed column.) The exempt procedures list will be evaluated at least annually.	Provider must have submitted at least 10 UR requests during the evaluation period. Requests may be any combination of IP and/or OP procedures. Providers who receive 100% on the random audits which are performed monthly.	Provider who is determined to receive a denial for medical necessity during random monthly 20% audit. QH and L&I will review any Provider receiving a denial the previous month. The provider warning letter will be mailed to the provider notifying them of the focused audit to be performed for the next 90 days. Focused audit will consist of: 100% case audit for providers who submit 20 or less reviews in the previous three months 50% case audit for providers who submit 21 or more reviews in the previous three months. Providers who receive a denial during the focused case audit will proceed to removal of Group A status.	Provider who are on warning Group A status who receive a denial during the focused audit review. Provider who is determined to have any sanction or action against medical license. Provider who is not enrolled in the L&I provider network *effective 1/1/2013. Once a provider is removed from Group A status, they are ineligible for Group A consideration during the annual evaluation. The provider will be eligible in the following years annual evaluation based on the current Group A criteria.		Any repeat surgery request (same CPT code used) within 6 months requires full review. Any 3rd surgery request on same body part within 5 years requires full review. Any new or modified Department MTG's/ Guidelines introduced will be exempt for one year for all Group A providers.

 

PROCESS CHANGES:
L&I WILL: Send letter to all Group A physicians if a new/modified guideline is introduced regarding change in guidelines and change to full review for those procedures for one year effective immediately	QUALIS HEALTH WILL: Monthly Perform both random and focused audits on a monthly basis Recommend to L&I those providers who should be: Placed on a warning status based on the random audit results Removed from Group A status based on focused audit results Annually Recommend to L&I suggested changes to the Provider A letters (refer to agreed upon schedule)

How to make a request

• Group A providers will not be required to submit clinical information, chart notes or diagnostic reports to Qualis for most outpatient surgeries.
• Group A providers will be required to submit a notification request form to Qualis Health. The following information is required:
• Planned procedure, description and CPT codes
• Place of service
• Date or anticipated date of service
• Office contact name and phone number

• Exceptions, providers must follow the full clinic review for the following:
• All spine procedures and surgery for Thoracic Outlet Syndrome.
• Uncommon procedures
• Procedures where there are no guidelines or criteria
• Procedures with specific provider limitations
• Claims managers may require full clinical review on:
• complex cases or
• when there are multiple differing medical treatment recommendations or opinions.

Utilization Review Definitions

 

Frequently Asked Questions (FAQs)

Advanced Imaging UR FAQs

• How do I submit a request for advanced imaging?
  1. Registration is required.
  2. Enter claim and request information on iExchange®, include your contact information in the "comments" area.
  3. Complete the checklist. The checklist that appears is based on the CPT code entered.
  4. Upon completion of the checklist a prior authorization number and a “recommendation” of approve or pend will appear. Final authorization determination will be made by the department.
  5. You will receive communication on authorization status from the department by phone, fax or letter.
• How do I complete the Advanced Imaging online checklist?
  1. First determine who will complete the online checklist.
  2. It may be helpful to print out the check-list prior to completing it online.
  3. Enter correct CPT code and appropriate checklist will appear.
  4. Answer all questions on the checklist.

  Get a copy of Qualis Health iExchange® Training manual here.

• What do I do if the condition/injury is not included on the checklist, but the code requires UR?

  If the code requires review, but the condition/injury is not included in the checklist, for example brain MRI, complete the checklist that appears on the screen and check all boxes that would apply. There will be check boxes for N/A if the condition does not apply. You may enter additional information in the comments section that will help us determine if the request is appropriate.

• Can an imaging facility request/submit requests for Advanced Imaging Authorization?

  YES. If a provider has given the imaging facility complete clinical information to answer/complete the iExchange® on-line check-list, or if the imaging facility has access to medical records to complete the online checklist.

• What if I'm not registered with OneHealthPort and /or iExchange®.

  Register for OneHealthPort to access iExchange® go to the Qualis Health website

• What if the imaging facility is unknown at the time the request is being made?

  When completing the checklist online if the facility is unknown, there is an "imaging unknown facility" listed in the dropdown box.

• What are the Advanced Imaging "Guidelines" and where do I find them?

  Read the guidelines/checklists. Learn how the guidelines were selected and rated by the AIM workgroup.

• What type of imaging requires review?

  MRI of the spine, upper and lower extremity requires review. CT and MRI of the brain also require review.

  Codes requiring review:

  Spine	Upper extremity	Lower extremity	Head/Brain
  72141	73221	73721	70450
  72142	73222	73722	70460
  72146	73223	73723	70470
  72147	73218	73718	70551
  72148	73219	73719	70552
  72149	73220	73720	70553
  72156
  72157
  72158

• What if I need to change a code that was already submitted?

  Contact Diane Walker with corrected codes either by phone at 360-902-5182 or fax 360-902-5600.

• What if the date of services for an Advanced Imaging is unknown?

  When making a request, a specific date is not required. A date span of two months will be accepted. If a specific date is known it is appropriate to enter that date. Retrospective reviews should reflect the actual date of service. Date spans will be authorized in two-month timeframes.

• How are Retrospective reviews submitted?
  1. Log on to OneHealthPort to access iExchange®.
  2. Enter claim and request information on iExchange®, include your contact information in the "comments" area and “actual date of service requested, note in comments that review is retrospective.”
  3. Complete the checklist. The checklist that appears is based on the CPT code entered.
  4. Upon completion of the checklist a prior authorization number and a "recommendation" of approve or pend will appear. Final authorization determination will be made by the department.
  5. You will receive communication on authorization status from the department by phone, fax or letter.
• What does it mean if I receive a "PEND" notification when submitting a request on-line with iExchange®?

  A "PEND" recommendation means that an approval could not be issued, because the request did not meet the guideline in which case there is a high likelihood of a denial, or there were errors or inconsistency on the request form. You may be called for clarification, and then final authorization determination will be made by the department.

• Does the UR requirement apply to self-insurers or Crime Victims?

  No. SIE and Crime Victims, however, require prior authorization.
  For Self-Insured Claims, contact the self-insured employer (SIE) or the third party administrator (TPA) to request authorization. View a list of SIE/TPAs.
  For Crime Victims claims, request authorization for advanced imaging by contacting the program's claim manager by phone at 800-762-3716 or fax at 360-902-5333.

• Is Advanced Imaging UR required for in-patient admissions?

  No. Advanced Imaging done during an "approved" in-patient admission does not require a separate review. Review for the services will be part of the inpatient review.

  Is UR required for imaging done in the Emergency Department or urgent care setting?

  Yes. If services are performed on an urgent basis the request can be made retrospectively. If there is an inpatient admission and the imaging charges are part of a hospital stay, then a separate review would not be required.

• How will I know if L&I has authorized the Advanced Imaging request?

  You will receive one of the following:

  1. A phone call.
  2. A letter.
  3. You may view authorization in the Claim and Account Center.

  Telephone calls will be made to the person identified as the contact listed in the comments section of the request. Letters will be mailed to the address associated with the L&I provider ID.

• How does an IME Provider obtain prior authorization?

  IME providers should notify the department directly if advanced imaging services are being requested as part of an IME. Qualis UR review is not required for advanced imaging that is related to the IME. Notification is required and prior authorization numbers will be issued. Please follow the steps below:

  1. Call Diane Walker, Occupational Nurse Consultant at 360-902-5182 or fax information to 360-902-5600 (Attention Diane Walker). You will be contacted by phone and given an authorization number which will be needed by the imaging provider for payment.
  2. Print or document otherwise the prior authorization number for records and reference.

  When contacting Diane Walker at the department please be prepared with the following information:

  1. Name and phone number of person making this request.
  2. The reason for requesting imaging.
  3. Injured worker's full name.
  4. Injured worker's date of birth.
  5. Injured worker's L&I claim number.
  6. Type of imaging requesting; description (body part and body side) and CPT code.
  7. Name and L&I provider number of imaging facility.
  8. Name and L&I provider number of requesting IME provider.
  9. Date of service.
  10. Diagnosis code.
  11. Date of injury.
• What can I do if I don't agree with a denial recommendation?

  If a provider does not agree with a denial recommendation they may submit a request for “full re-review”; Fax request and clinical information to Qualis Health at (877) 665-0383 or (206) 366-3378 and include the following:

  1. Include last 30 days of chart notes with most recent physical exam.
  2. Include explanation that supports request for full re-review.
• What do I need to know about billing for Advanced Imaging study?

  Prior Authorization number must be included on the bill.

  Do I need authorization to bill for professional component (modifier 26) for re-reading advanced imaging?

  Re-read of an MRI would need to be done within the authorized date span. If the re-read is done outside of the authorized date span, contact Diane Walker, Occupational Nurse Consultant at 360-902-5182 or via fax at 360-902-5600 so that the authorized date span can be adjusted.

  How do I request authorization if provider has no computer access?

  You can submit requests to Qualis Health:

  • By phone at 800-541-2894 or 206-366-3360.
  • By fax at 877-665-0383 or 206-366-3378.

  ---

  PT and OT Therapy UR FAQs

  

  • Why is L&I doing the utilization review (UR)?

    To support L&I's mission to purchase proper and necessary care for injured workers.

  • Does the UR requirement apply to self-insurers?

    No.

  • Can occupational therapists use the OT/PT Treatment Authorization Fax Request form?

    Yes, the form is available at: Occupational or Physical Therapy Treatment Authorization Fax Request (F248-055-000).

  • What documentation does L&I need?

    You can review L&I's requirements for therapy documentation on our Physical, Occupational and Massage Therapy web site.
    This will provide you guidance when documenting the worker's progress in order to authorize continued treatment. Continue to send your progress reports and daily documentation to L&I.

  • When do I submit a request to Qualis for standard outpatient PT/OT treatment?

    Submit your request to Qualis if the current authorization period or number of visits:

    • Has expired or will expire within the next 2 weeks and
    • The worker has completed or will have completed 24 physical or occupational therapy visits.
  • May I continue treating the worker while waiting for Qualis' recommendation?

    If it is your professional opinion that it would be detrimental to delay or disrupt treatment, continue treatment. The purpose of UR is related to payment by L&I for medically necessary services not to determine if treatment is to be provided.

  • What documentation does Qualis need?

    Standard OT/PT Outpatient Treatment
    Submit electronically using the Qualis iExchange® system (www.qualishealth.org).
    OR
    Fax submission to Qualis:

    • A Review Request Form (www.qualishealth.org).
      AND
    • A Physical/Occupational Therapy Questionnaire (www.qualishealth.org).

    Work Conditioning
    Electronic submission: Not available for work conditioning requests.
    Fax submission to Qualis:

    • A Review Request Form (www.qualishealth.org).
    • Attending physician request for work conditioning
      OR
      Signature agreeing with therapist's recommendation.
    • Evaluation or Progress Report.
      • Performance based physical capacities evaluation.
        OR
      • Clinic progress reports (latest and 1 prior report).
        OR
      • Work conditioning evaluation.

    Make sure your documentation includes:

    • Plan of care (POC) to address the gaps in worker's current abilities and what's required to return-to-work and
    • Anticipated duration and visits for total POC and
    • Worker's prognosis for meeting goals.

    Qualis may recommend a work conditioning evaluation prior to considering a work conditioning plan of care if the:

    • Above documents are not made available.
    • Worker has not been actively participating in therapy for more than 3 months.
    • Worker has reached a plateau in therapy.
  • How do I know Qualis received my fax request?

    Qualis will provide you with a reference number. Contact Qualis if you do not receive this number after 4 days.

  • What happens if I provide services beyond the 24th visit without review or authorization?

    Your bills will be denied. You will be advised to contact Qualis for a retro-review. If Qualis says additional therapy is okay and the claim manager approves, then you may resubmit your bills.

  • Will payment be authorized while treating a worker during the Qualis review process?

    If your request is timely and there no prior therapy treatment denials, Qualis will adjust the date to cover visits provided up to the date you learn from them of a possible denial recommendation. Timely request means that the request was submitted before your current authorization expired or before 24 visits have occurred. The claim manager makes the final decision of payment.

  • How do I submit my request when I've never seen this worker before?

    Fill out both the request and the questionnaire as completely as possible. When the answer is unknown, write "unknown". Qualis may initially recommend an evaluation and 5 visits in order for you to develop a plan of care and demonstrate functional progress.

  • Is there any situation where the visit count starts over?

    No. All visits are combined and do not start back to number 1. This includes services:

    • Following surgery.
    • With a new condition, on the same claim.
    • With a referral from a different doctor.
    • When the worker changes therapists.
  • Is there a limit to the number of visits I can request through UR?

    No. But Qualis is not likely to recommend more than 12 visits at any one time for outpatient treatment and 20 visits for work conditioning. You can request fewer visits.

  • Does Qualis prefer requests to be submitted online?

    Yes. The preferred method for outpatient therapy requests is usingiExchange® on the Qualis web site (www.qualishealth.org).

  • How will I know what Qualis' recommendation is?

    Qualis will call your office to give you their recommendation.

  • How can I check on the status of the request for authorization?

    You can contact Qualis 1‑800‑541‑2894. If Qualis has completed the review, call L&I's Provider Hotline 1‑800‑848‑0811 to check the status of the claim manager's decision.

  • What is InterQual® criterion, How can I get a copy?

    InterQual® criterion is a nationally recognized criterion developed by McKesson Health Solutions LLC. It is designed to assist an organization with assessing the medical necessity and appropriateness of health care services to patients. You may obtain the InterQual® criterion on a lease basis from McKesson by:

    • Phone: 1‑800‑522‑6780
      OR
    • Online: InterQual (www.interqual.com).
  • How can I prevent delays for continued therapy?

    In order to prevent delay, submit utilization review requests prior to completing the 24th visit even if you do not have the attending doctor's referral.

  • What would Qualis do if there are no attending doctor (AP) orders?

    If there is no AP order on file, Qualis may contact the doctor to verify that the services are necessary.

  • How often does the worker need to follow up with the doctor?

    Depends upon the original prescription. Qualis will be looking for evidence of ongoing management of the worker's treatment.

  • Can occupational/physical therapists get access to the Claim and Account Center?

    Yes, if the injured worker gives permission for you to access their account. Customer support for the Claim and Account Center is available at 360‑902‑5999 (8 a.m. to 5 p.m. Monday through Friday).

  • Can authorization be added to the Interactive Voice Response (IVR)?

    Not at this time. However, we are looking at the possibility of adding this. You may still use the IVR system at 1‑800‑831‑5227 to find out claim status, accepted diagnosis and procedure codes, and claim manager's phone number.

  • Does treatment by a licensed massage practitioner require UR?

    No. Authorization may be requested using the LMP Treatment Authorization FAX Request form (F248‑357‑000).