| Physical & Occupational Therapy UR |  | |
Q & A on utilization reviews of physical and occupational therapy
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.
- Performance based physical capacities 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.
- A Review Request Form (www.qualishealth.org).
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 using iEXCHANGE 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).
- Phone: 1‑800‑522‑6780
- 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).
