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.

What requires UR review

  • All inpatient hospitalizations.
  • Selected outpatient surgical procedures.
  • Physical Medicine, PT, and OT after the 24th visit.
  • Advanced Imaging Studies.
  • Spinal Injections.

UR Process

Provider submits request via web portal, OneHealthPort. We mandate UR requests be web based.

For assistance with portal access, contact Comagine Health at 800-541-2894

Comagine Health uses the Department's 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.

Non-initiated claims

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.

Inpatient & Outpatient Requests

All acute care inpatient stays require review

Selected outpatient procedures require review

To determine which procedures require review, refer to our Fee Schedule Lookup (Make sure to check the Updates & Corrections tab for any changes to the Payment Policies or Fee Schedules).

Comagine Health (formerly Qualis Health) provides web-based utilization review via Comagine Health Provider Portal, which allows providers to securely submit, update and review requests.

Request a Review

  1. Refer to L&I's Medical Treatment Guidelines for information on what specific clinical documentation is required for selected procedures. Reviews will be delayed when incomplete information is submitted. Only submit documentation necessary to evaluate the requested procedure.
  2. Sign In to Comagine Health Provider Portal.
  3. For questions call Comagine Health: 1-800-541-2894 or 206-366-3360

What to expect

Prospective Reviews
When Comagine receives a request for a prospective review with all the necessary clinical information:

  1. A Comagine review nurse will compare the clinical information to the Department’s Medical Treatment Guidelines or Interqual criteria.
  2. If the clinical information supplied with the request does not meet the guidelines and/or the criteria, the nurse will refer the request to a physician consultant.
    1. If the physician consultant cannot recommend approval, an offer to discuss the clinical information is made to requesting physician. Based on available information, the physician consultant will make a recommendation. During the review process there may be opportunities for providers to discuss pending decisions with the reviewing physician.
  3. If the requesting provider disagrees with the determination, a re-review may be requested. Re-reviews are performed by specialty-matched physicians.
  4. Comagine Health issues a “notification number” for completed reviews. After authorization by the claim manager, the “notification number” will become L&I’s prior Authorization number.

Concurrent Reviews
Comagine Health will perform a concurrent review on inpatient stays if continued hospitalization is required beyond the initial or subsequent recommended length of stay.

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

Additions or changes to the CPT© codes or dates of service

For all inpatient reviews or outpatient procedures that need changes to CPT© codes or dates of service, contact:

  • Comagine Health at phone: 800-541-2894
  • Fax 877-665-0383

Please include:

  • Coversheet with the additions or changes to the CPT© codes or DOS being requested.
  • Copy of the operative report.

For more information:
OMD UR unit: phone: 360 902-5036, fax: 360 902-5600
Comagine Health: phone: 800 541-2894

Advanced Imaging

We require prior authorization UR for advanced imaging, which includes spine and extremity MRIs, Brain MRI, Head CT, cardiac imaging and PET scans. Check the Fee Schedule Lookup (Make sure to check the Updates & Corrections tab for any changes to the Payment Policies or Fee Schedules.) for specific requirements on advanced imaging prior authorization.

Refer to our Evidenced-based Imaging Guidelines for information on what specific clinical information is required for selected procedures. Checklists were developed for requesting providers to expedite the process.

We require web based submission of requests through the Comagine Health Provider Portal.

Requesting a review for Advanced Imaging

Questionnaires are posted on the Comagine site for the following selected imaging procedures:

UR Process

Most advanced imaging reviews are questionnaire based. The review recommendation is based on the answers submitted by the provider. Incomplete or duplicate requests will show as pended. If the questionnaire answers do not meet the guideline, the request will PEND initially, then be reviewed at Comagine and sent to us with a recommendation.

Full clinical review is required when there has been a questionnaire denial, or when questionnaire does not apply. Submit medical records only on full clinical reviews, records not needed with questionnaire requests.

The Utilization Review Program applies only to claims that are adjudicated by the State Fund

For more information:
OMD UR unit: phone: 360 902-5036, fax: 360 902-5600
Comagine Health: phone: 800 541-2894

Physical & Occupational Therapy UR

Physical (PT) and Occupational therapy (OT) visits require UR review after the 24th visit. PT and OT visits accumulate separately. Each discipline is allowed 12 visits without approval. The next 12 visits must be authorized through the Provider Hotline 800-848-0811.

Visit counts accrue per individual claim. New referrals, restart of therapy following surgery, or treatment of new conditions on the same claim do not reset the count.

If Work Conditioning is requested with both PT and OT and greater than 24 visits have previously occurred for either therapy discipline, utilization review is required.

We require web based submission of requests through the Comagine Health Provider Portal.

Request a review from Comagine Health

  1. For outpatient physical/occupational therapy beyond 24 visits, the therapy provider will:
  2. For work conditioning, provider will send to Comagine:
  3. Evaluation or Progress Report, including one of these:
    • Performance based physical capacities evaluation
    • Clinic progress reports (latest and 1 prior report)
    • Work conditioning evaluation.

Note: Comagine may request additional documentation. A separate records release is not required. Utilization Review does not change the requirement to submit required documentation to the Department. Refer to the documentation tab on our Physical, Occupational, and Massage Therapy page for additional information.

A Comagine therapist reviews the request and compares clinical information to InterQual® criteria. If InterQual® criteria:

  • Are met, the Comagine therapist recommends approval.
  • Are not met, the request is referred to a physician reviewer. If the physician reviewer does not believe therapy is warranted, Comagine will notify the therapy provider of a potential denial, and options/opportunity for re-review .
  • Comagine sends a report with a recommendation to L&I, and the Claims manager makes and communicates the final decision to the provider.

The Utilization Review Program applies only to claims that are adjudicated by the State Fund

For more information:
OMD UR unit: phone: 360 902-5036, fax: 360 902-5600
Comagine Health Phone: 800 541-2894

UR Simplification (Group A Providers)

Providers to not 'apply' for Group A status. Group A status is awarded based on a retroactive review of the previous year's surgical requests. See criteria below.

Reduced UR requirement for providers who had consistent UR approval recommendations does not increase utilization of unauthorized services.

Providers - Criteria to Determine Status

New

  • Provider must have submitted at least 10 UR requests during the evaluation period. Requests may be any combination of IP and/or OP procedures. Provider must have 100% approval on all UR requests.
  • Review period will be based on previous 12 FULL months of data.

Continued

  • Providers must maintain 100% approval to remain Group A. Compliance will be determined by a monthly random audit of at least 20% of the Group A requests. And/or full clinical reviews completed on exception cases
  • If a request is up for audit and the relevant clinical records are not available in the image file, the provider, upon request from Comagine Health, must supply records for audit or be subject to possible removal from Group A status.

Warning

  • Provider who is determined to receive a denial for requests not meeting medical treatment guidelines or criteria during audit or when full clinical review is completed, may be subject to warning letter.
  • Comagine Health and L&I will review any Provider receiving a denial The denial may result in removal from the program or a probationary period during which full review for medical necessity will be required for all requests. Denials during a probationary period may lead to immediate removal from the Group A program.
  • The warning letter will be mailed to the provider notifying them of the focused audit or probationary status. Focused audit will consist of: 100% case audit for providers who submitted 20 or less reviews in the previous three months

Or

  • At least 50% case audit for providers who submitted 21 or more reviews in the previous three months.
  • Providers who receive a denial during the focused case audit or while on probationary status may be subject to removal of Group A status.

Removal

  • Reasons for Removal:
    • A provider on warning status who receives a denial during the focused audit review.
    • Provider who is not enrolled in the L&I provider network.
  • Once a provider is removed from Group A status, they are ineligible for Group A consideration during that year’s annual evaluation. The provider will be eligible in the following annual evaluation based on the current Group A criteria or after at least 12 months of full clinical reviews.

Cases Allowed

Proposed Changes

  • Any repeat surgery request (same CPT code used) within 6 months requires full review.
  • Any 3rd surgery request on same body part within 5 years requires full review.
  • Any new or modified Department MTG's/ Guidelines introduced will be exempt for one year for all Group A providers.

How Group A providers make a request for a procedure

They are still required to submit an online notification to Comagine Health using the OneHealthPort Single Sign-On page.

The submission includes the following information:

  • Planned procedure, written description (specific plan, e.g. Rotator cuff repair versus “shoulder surgery”)
  • CPT codes for planned procedure and ICD-10 diagnosis code
  • Place of service
  • Scheduled date of service if known
  • Office contact name and phone number

The reduced UR requirements apply to selected outpatient procedures and may be subject to change. Procedures that require full clinical review (not eligible for reduced UR requirements) include all spine procedures, thoracic outlet syndrome surgery, uncommon or unusual procedures and procedures with specific provider limitations. All inpatient procedures require full clinical review.

Auditing

Comagine Health will perform audits retrospectively (after submission of the request which may or may not be after the surgical procedure is performed) or based on a Group A providers performance.

Auditing involves a clinical reviewer accessing the medical records to determine if the surgery as requested meets the applicable medical treatment guideline (MTG). For requests that do not appear to meet the MTG, a physician reviewer is consulted. If it is determined that the MTG is not met, the provider can be placed on warning or probation. Further requests found not to meet criteria can lead to immediate removal from the Group A program.

Spinal Injections

We require prior authorization UR for spinal injections, which includes Diagnostic Medial Branch Blocks, Epidural injections, Selective Nerve Root Blocks, Caudal Injections, Sacroiliac joint Injections and some Intrathecal injections.

Refer to our Spinal Injection Guideline for information on what specific clinical information is required for selected procedures. Checklists were developed for requesting providers to expedite the process.

The Utilization Review Program applies only to claims that are adjudicated by the State Fund.

We require web based submission of requests through the Comagine Health Provider Portal.

Requesting a review for a Spinal Injection

Questionnaires are posted on the Comagine site for the following:

  • Sacroiliac Joint Injections
  • Medial Branch Block and Diagnostic Facet injection
  • Therapeutic Epidural Injections

UR PROCESS

Most spinal injection reviews are questionnaire based. The review recommendation is based on the answers submitted by the provider. Incomplete or duplicate requests will show as pended. If the questionnaire answers do not meet the guideline, the request will PEND initially, then be reviewed at Comagine and sent to L&I with a recommendation.

Full clinical review is required when there has been a questionnaire denial, or when questionnaire does not apply. Submit medical records only on full clinical reviews, records not needed with questionnaire requests.