What is Utilization Review and how does it work?

The utilization review process compares requests for medical services ("utilization") to treatment guidelines that are deemed appropriate for such services and includes the preparation of a recommendation based on that comparison. The Utilization Review Program applies only to claims that are adjudicated by the State Fund. The program applies to both physicians and facilities.

Goal

The utilization review process supports the agency’s mission to purchase only proper and necessary care for injured workers.

Definitions

Utilization Review

The process of comparing requests for medical services (“utilization”) to guidelines or criteria that are deemed appropriate for such services, and making a recommendation based on that comparison.

Prospective Review

Those conducted prior to the delivery of the services requested. Prospective reviews may be for inpatient or outpatient services.

Concurrent Review

Those performed while the worker is still hospitalized and services are being provided. Concurrent review also occurs with additional physical medicine.

Retrospective Review

Those performed after the requested service or procedure has already occurred and the worker has been discharged. Retrospective reviews may be inpatient or outpatient

Re-Review

Reviews requested by the provider or claim manager after a denial recommendation. Re-review may be requested during the initial review discussion or after claim manager decision. Re-review is performed by a matched specialty physician.

Group A Provider

Those providers with 100% UR approval recommendations when they performed 10 or more reviews during the one year review period.

Responsibility

The Office of the Medical Director (OMD):

• manages the contract with the L&I UR vendor and
• monitors the quality of reviews by the UR vendor.

UR Vendor Qualis Health:

• Review cases against L&I’s Medical Treatment Guidelines or InterQual criteria
• Recommend a course of action to the L&I Claim Manager.

Avoid Utilization Review Delays
To reduce or avoid Utilization Review delays, follow these suggestions.

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.

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.

How to bill L&I for services authorized following utilization review

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

Services beyond 24 visits, need to have the 10-digit prior authorization number on the bill:

• On the CMS 1500 (F245-127-000), field 23, PRIOR AUTHORIZATION NUMBER.
• On the UB04 HCFA 1450 (F245-367-000), field 63, TREATMENT AUTHORIZATION CODES.

If there is no prior authorization, a retrospective review must be done by Qualis Health before the bill can be considered for payment.

For more information, see the Physical Medicine Services section (page 55) in L&I's Payment Policy (1,189 KB/3 min. PDF).

For more information on documenting and billing for your services:

See Physical, Occupational and Massage Therapy.

Q & A on utilization reviews of physical and occupational therapy

• Why is L&I doing the utilization review (UR)?

  To support L&I's mission to purchase proper and necessary care for injured workers.

• Does the UR requirement apply to self-insurers?

  No.

• Can occupational therapists use the OT/PT Treatment Authorization Fax Request form?

  Yes, the form is available at: Occupational or Physical Therapy Treatment Authorization Fax Request (F248-055-000).

• What documentation does L&I need?

  You can review L&I's requirements for therapy documentation on our Physical, Occupational and Massage Therapy web site.

  This will provide you guidance when documenting the worker's progress in order to authorize continued treatment. Continue to send your progress reports and daily documentation to L&I.

• When do I submit a request to Qualis for standard outpatient PT/OT treatment?

  Submit your request to Qualis if the current authorization period or number of visits:

  • Has expired or will expire within the next 2 weeks and
  • The worker has completed or will have completed 24 physical or occupational therapy visits.
• May I continue treating the worker while waiting for Qualis' recommendation?

  If it is your professional opinion that it would be detrimental to delay or disrupt treatment, continue treatment. The purpose of UR is related to payment by L&I for medically necessary services not to determine if treatment is to be provided.

• What documentation does Qualis need?

  Standard OT/PT Outpatient Treatment

  Submit electronically using the Qualis iEXCHANGE system (www.qualishealth.org).

  OR

  Fax submission to Qualis:

  • A Review Request Form (www.qualishealth.org).
    AND
  • A Physical/Occupational Therapy Questionnaire (www.qualishealth.org).

  Work Conditioning

  Electronic submission: Not available for work conditioning requests.

  Fax submission to Qualis:

  1. A Review Request Form (www.qualishealth.org).
  2. Attending physician request for work conditioning
     OR
     Signature agreeing with therapist's recommendation.
  3. Evaluation or Progress Report.
     • Performance based physical capacities evaluation.
       OR
     • Clinic progress reports (latest and 1 prior report).
       OR
     • Work conditioning evaluation.

  Make sure your documentation includes:

  • Plan of care (POC) to address the gaps in worker's current abilities and what's required to return-to-work and
  • Anticipated duration and visits for total POC and
  • Worker's prognosis for meeting goals.

  Qualis may recommend a work conditioning evaluation prior to considering a work conditioning plan of care if the:

  • Above documents are not made available.
  • Worker has not been actively participating in therapy for more than 3 months.
  • Worker has reached a plateau in therapy.
• How do I know Qualis received my fax request?

  Qualis will provide you with a reference number. Contact Qualis if you do not receive this number after 4 days.

• What happens if I provide services beyond the 24th visit without review or authorization?

  Your bills will be denied. You will be advised to contact Qualis for a retro-review. If Qualis says additional therapy is okay and the claim manager approves, then you may resubmit your bills.

• Will payment be authorized while treating a worker during the Qualis review process?

  If your request is timely and there no prior therapy treatment denials, Qualis will adjust the date to cover visits provided up to the date you learn from them of a possible denial recommendation. Timely request means that the request was submitted before your current authorization expired or before 24 visits have occurred. The claim manager makes the final decision of payment.

• How do I submit my request when I've never seen this worker before?

  Fill out both the request and the questionnaire as completely as possible. When the answer is unknown, write "unknown". Qualis may initially recommend an evaluation and 5 visits in order for you to develop a plan of care and demonstrate functional progress.

• Is there any situation where the visit count starts over?

  No. All visits are combined and do not start back to number 1. This includes services:

  • Following surgery.
  • With a new condition, on the same claim.
  • With a referral from a different doctor.
  • When the worker changes therapists.
• Is there a limit to the number of visits I can request through UR?

  No. But Qualis is not likely to recommend more than 12 visits at any one time for outpatient treatment and 20 visits for work conditioning. You can request fewer visits.

• Does Qualis prefer requests to be submitted online?

  Yes. The preferred method for outpatient therapy requests is using iEXCHANGE on the Qualis web site (www.qualishealth.org).

• How will I know what Qualis' recommendation is?

  Qualis will call your office to give you their recommendation.

• How can I check on the status of the request for authorization?

  You can contact Qualis 1‑800‑541‑2894. If Qualis has completed the review, call L&I's Provider Hotline 1‑800‑848‑0811 to check the status of the claim manager's decision.

• What is InterQual® criterion, How can I get a copy?

  InterQual® criterion is a nationally recognized criterion developed by McKesson Health Solutions LLC. It is designed to assist an organization with assessing the medical necessity and appropriateness of health care services to patients. You may obtain the InterQual® criterion on a lease basis from McKesson by:

  • Phone: 1‑800‑522‑6780
    OR
  • Online: InterQual (www.interqual.com).
• How can I prevent delays for continued therapy?

  In order to prevent delay, submit utilization review requests prior to completing the 24th visit even if you do not have the attending doctor's referral.

• What would Qualis do if there are no attending doctor (AP) orders?

  If there is no AP order on file, Qualis may contact the doctor to verify that the services are necessary.

• How often does the worker need to follow up with the doctor?

  Depends upon the original prescription. Qualis will be looking for evidence of ongoing management of the worker's treatment.

• Can occupational/physical therapists get access to the Claim and Account Center?

  Yes, if the injured worker gives permission for you to access their account. Customer support for the Claim and Account Center is available at 360‑902‑5999 (8 a.m. to 5 p.m. Monday through Friday).

• Can authorization be added to the Interactive Voice Response (IVR)?

  Not at this time. However, we are looking at the possibility of adding this. You may still use the IVR system at 1‑800‑831‑5227 to find out claim status, accepted diagnosis and procedure codes, and claim manager's phone number.

• Does treatment by a licensed massage practitioner require UR?

  No. Authorization may be requested using the LMP Treatment Authorization FAX Request form (F248‑357‑000).

Contact Information

Labor & Industries

Nikki D'Urso
Uitlization Review Program Manager
Office of the Medical Director
360-902-5034
Durn235@Lni.wa.gov

For coding additions or changes

Lucille LaPalm
Occupational Nurse Consultant
360-902-6377

For questions regarding Medical Treatment Guidelines

Simone Javaher
Occupational Nurse Consultant
360-902-5762

Qualis Health

Lori Rice
Director of Workers’ Compensation Services
Qualis Health
(800) 541-2894

The following websites contain information on the Department's Utilization Review Program and Qualis Health:

www.lni.wa.gov/ClaimsIns/Providers/Treatment/UtilReview/default.asp

http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/UtilReview/Therapy/default.asp

http://qualishealth.org/

Avoid Utilization Review Delays
To reduce or avoid Utilization Review delays, follow these suggestions.

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.