| Physical & Occupational Therapy UR |  | |
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What treatment requires utilization review?
The information on this site is effective July 1, 2007.
Utilization review IS required for:
All outpatient physical and occupational therapy services exceeding 24 visits per claim regardless of the clinical setting.
Note: Work hardening does not require utilization review, but does require prior authorization by the claim manager.
Qualis Health will perform the review of physical and occupational therapy using InterQual®. They will make a recommendation to L&I's claim manager to approve or deny.
Claim managers make the final decision to authorize or deny a request for services.
Utilization review IS NOT required for standard outpatient therapy visits under 24 or for any of these situations:
- Work hardening.
- Performance-based physical capacities evaluations.
- Outpatient pain clinics.
- Work evaluations.
- Job modifications/pre-job accommodation consultations.
| Utilization Review Requirements | ||
| Visits | Needs authorization? | Needs utilization review? |
| 1 - 12 | No | No |
| 13 - 24 | Yes, by L&I. Read more about authorization for these services. | No |
| 25 + | Yes, by L&I | Yes, Qualis Health will make a recommendation to L&I's claim manager. The claim manager makes the final decision. |
