Avoid UR Delays

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How to reduce or avoid Utilization Review delays

1. Check the claim status.
• Has a decision been made on the allowance of the claim?
• Is the claim open? Do you need to submit a reopening application?
2. Verify that the condition being treated is accepted under the claim.
3. If a claim has not been submitted, complete a Report of Accident (ROA) form.
• Fax all ROAs to: 1-800-941-2976.
• You can still request utilization review; however, the request can not be processed until the claim is initiated.
4. Use our checklist on the Qualis Health site.
5. Submit all the information Qualis needs:
• Patient name.
• L&I claim number.
• Proposed or actual admission date.
• ICD-9-CM admitting diagnosis(es).
• CPT™ codes planned procedures.
• L&I provider number.
• Relevant clinical information.
• Convenient time for nurse or physican consultant to call physician back.
6. Refer to L&I's Medical Treatment Guidelines for information on what specific clinical information is required for selected procedures. The guidelines are divided into the following sections:
• Introduction and Guideline Process.
• Hospitalization for Low Back Pain.
• Cauda Equina.
• Knee Surgery.
• Single Cervical Nerve Root.
• Single Lumbar Nerve Root (Lumbar Laminectomy).
• Ankle/Foot Surgery.
• MRI Lumbar Spine.
• Shoulder Surgery.
• Lumbar Fusion.
• Thoracic Outlet Surgery.
• Carpal Tunnel Syndrome.
• Psychiatric and Psychological Evaluation.
• Porphyria.
• Complex Regional Pain Syndrome (CRPS).
• Fibromyalgia.
• Controlled Substances.
• Outpatient Prescription of Oral Opioids for Chronic.
• Non-cancer Pain
7. Call back quickly on peer-to-peer calls from Qualis.
8. After surgery, if you need to add or change CPT™ codes for outpatient surgeries, fax the operative report and coversheet with the codes that need to be added or replaced to OMDUR at 360-902-6315.