| Utilization Review |  | |
UR Simplification (Group A Providers)
Reduced UR requirement for providers who had consistent UR approval recommendations does not increase utilization of unauthorized services.
Which providers
- Have at least 10 UR request and with 100% UR approval recommendations for one year
Selection & Removal Process
- Review of all provider’s UR data will be completed in August each year
- Providers with ten or more UR request during January through December and who had 100% UR approval will be added to Group A .
- Providers that have received UR denial recommendations or who are found on retrospective audit to not meet either L&I’s Medical Treatment Guidelines or InterQual criteria will be removed from the list.
- Twenty percent of Group A provider requests will be reviewed retrospectively to determine compliance to L&I policies.
- All providers whose status changes will be notified by letter.
What’s different
- These providers will not be required to submit clinical information, chart notes or diagnostic reports to Qualis for most outpatient surgeries.
- Group A providers will be required to submit a notification request form to Qualis Health. The following information is required:
- Planned procedure, description and CPT codes
- Place of service
- Date or anticipated date of service
- Office contact name and phone number
- Exceptions:
- All spine procedures and surgery for Thoracic Outlet Syndrome.
- Uncommon procedures
- Procedures where there are no guidelines or criteria
- Procedures with specific provider limitations
- Claims managers may request UR on
- complex cases or
- when there are multiple differing medical treatment recommendations or opinions.
How are Providers Selected
- In August each year the Group A list will be updated.
- In July each year UR data for the previous year will be reviewed.
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.
