The utilization review (UR) process compares requests for medical services to appropriate treatment guidelines and includes a recommendation based on that comparison
Utilization Review supports our mission to purchase only proper and necessary care for injured workers.
- The Utilization Review Program only applies to claims that are adjudicated by the State Fund.
- We contract with Comagine Health (formerly Qualis Health).
- The program applies to both providers and facilities.
For assistance with portal access, contact Comagine Health at 800-541-2894
Comagine Health uses our Medical Treatment Guidelines, Health Technology Clinical Committee (HTCC) decisions and InterQual criteria to evaluate requested services.
If request meets guidelines or criteria, approval recommended.
If request does not meet guidelines or criteria, physician review is initiated.
- If physician reviewer unable to recommend approval, provider will be notified and requesting provider has the opportunity to discuss the request with Comagine reviewer or provide additional information.
- Detailed clinical report is submitted to the Department.
- Options for re-review are detailed in the Comagine communication to the provider and in the Department letters.
The claim manager will issue the final determination and inform the requesting provider.
Comagine Health reviews requests for treatment or procedures for non-initiated claims in the same manner as initiated claims.
Our determination may be delayed until the claim has been initiated and assigned to a claim manager.
Office of the Medical Director (OMD) manages the UR contract.