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How to request utilization review (UR)

The information on this site is effective July 1, 2007.

1. 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 Review Request 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, the therapy provider may:
• Send Qualis:
• A Review Request Form and
• An attending physician request for work conditioning or
  A signature agreeing with the therapist's recommendation and
• An Evaluation or Progress Report, which has either:
• Performance based physical capacities evaluation or
• Clinic progress reports (latest and 1 prior report) or
• Work conditioning evaluation.

Note: Because QH does not have access to L&I claim records, you need to send documentation to QH when you request the UR. A separate records release is not required.



2. Qualis Health reviews the request.
1. A QH therapist compares clinical information to InterQual®. If InterQual®:
• Is met, the QH therapist makes a recommendation for approval.
• Is not met, the request is referred to a physician reviewer. QH will verbally notify your therapy clinic of a potential denial.
2. 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 physician.
  • The prescribing physician has 1 week to get back to the QH physician.
  • The QH physician makes a recommendation to approve or deny services.
3. If the prescribing physician disagrees with the recommendation, they:
• May request a re-review, which is conducted by a specialty matched physician reviewer.
3. QH sends a report with a recommendation to L&I.
4. QH notifies the therapy provider of the recommendation and provides a 10 digit reference number.
5. 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 or letter.
• If authorized, the 10 digit reference number becomes the prior authorization number.