• About
• Request a Review
• UR Simplification
• Contact Info

Review Process

Initial clinical review is conducted by a registered nurse or therapist

• does not meet guidelines or criteria, referred for physician review
  • physician reviewer unable to recommend approval
    • requesting physician has the opportunity to discuss the case

Non-initiated claims?

• Qualis Health will review requests for treatment or procedures on non-initiated claims in the same manner as initiated claims. Physicians and facilities must follow the same UR process, however, L&I’s determination will be delayed until the claim has been initiated and assigned to a claim manager. Decisions to proceed with appropriate medical care should be based on the providers’ best clinical judgment and not on the status of the request.

Criteria used for review

• Qualis Health uses the Department’s Medical Treatment Guidelines.
  • Guidelines are available at http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/TreatGuide/default.asp.
  • When there are no Department Medical Treatment Guidelines available, Qualis Health utilizes InterQaul criteria.

Qualis Health recommendations are sent to the L&I claim managers.

• The claim manager will review the information and recommendation made by Qualis Health and will then decide whether to authorize or deny the request.
• The claim manager will issue the final determination and inform the requesting provider.

What Requires Qualis Review

All inpatient hospitalizations

• Exceptions
  • inpatient chemical dependency treatment and
  • sub-acute stays,
    • such as skilled nursing facility, transitional care unit or other setting that is not an acute care stay
• Selected outpatient surgical procedures
  • Current outpatient procedures requiring UR see: http://www.qualishealth.org/cm/washington-landi/upload/ListofOutpatientProceduresRequiringUR.doc
  • Procedures may be added or deleted from the list due to
    • Code changes, or
    • Claim managers’ request
  • UR Simplification applies to most outpatient surgeries.
  • Some procedures/services may not require UR, but would still need to be authorized by claim managers.
• Physical Medicine:
  • Physical therapy, occupational therapy and work conditioning require UR review after the 24th visit.

How to request a review

Contact Qualis Health by one of the following modes of transmission:

• iExchange
  • Qualis Health’s preferred method of submitting UR requests
    • Secure internet application, Qualis Health web page at http://www.qualishealth.org/cm/washington-landi/web-based_um_request.cfm.
• Phone: 800 541-2894 or 206 366-3360
• Fax: 877 665-0383 (toll free) or 206 366-3378

Qualis Health’s Process

• Once Qualis Health receives a request for a prospective review (see "Definitions" section) with all the necessary clinical information,
  • a "notification number" will be assigned and
  • The case is forwarded to a nurse or therapist for review.
    • The nurse will compare the clinical information to either the Department’s Medical Treatment Guidelines or other criteria.
    • If the clinical information supplied with the request does not meet the guidelines and/or the criteria, the Qualis review nurse or therapist will refer the request to a physician consultant for review.
    • If the physician consultant can not recommend approval an offer to discuss the clincal information will be made to the requesting physician. Based on available information, the physician consultant will make a recommendation.
      • If the requesting physician disagrees with the recommendation for denial, a re-review may be requested. Re-review is performed by matched Specialty physicians.
• Qualis Health will notify the provider
  • when they have completed a review, of the notification number and who to contact at the department for authorization.
• After authorization by the claim manager the “notification number” will become the Department's Prior Authorization number.
• Qualis Health will perform a concurrent review (see "Definitions" section)
  • if continued hospitalization is required beyond the initial or subsequent recommended length of stay or
  • when additional physical therapy or occupational therapy visits are requested after initial recommendation.
• Qualis Health will perform a retrospective review (see "Definitions" section) in the same manner as a prospective review, only the services will have already been provided.

Additions or changes to the CPT codes or Dates of Service

• If the coding addition or change is for an inpatient review or for an outpatient procedure that has not yet occurred, please contact Qualis Health at 800 541-2894
• For changes in dates of service, contact Qualis Health at 800 541-2894.
• If the code addition or change is for an outpatient procedure that has already occurred,
  • contact L&I, Office of the Medical Director at 360 902-6377 or
  • fax your request, including a copy of the operative report to 360 902-6328

Please be advised that payment for services provided, may be delayed if the CPT codes and/or dates of service do not match those in the UR request.

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Avoid Utilization Review Delays
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Physical & Occupational Therapy Utilization Reviews

Find out what the procedures are to request a utilization review and to obtain authorization for physical and occupational therapy services.