Qualis Health has partnered with the Washington State Department of Labor & Industries (Washington L&I) to provide utilization review services for its Workers' Compensation Program. The success of this program depends on the collaborative relationship between providers, Washington L&I and Qualis Health. Qualis Health provides services to make sure eligible injured workers get the appropriate care where and when they need it.
Services We Provide for Washington L&I
Utilization reviews are conducted on a prospective, concurrent and/or retrospective basis employing Washington L&I's Medical Treatment Guidelines, if applicable; otherwise, Qualis Health applies InterQual criteria.
Qualis Health reviews inpatient admissions, a select list of outpatient procedures, specified advanced imaging studies and physical medicine services.
- Effective January 1, 2014: Revised Medical Treatment Guideline for Shoulder Care
The Department of Labor & Industries (L&I) Industrial Insurance Medical Advisory Committee has updated the Medical Treatment Guideline (MTG) for the treatment of Shoulder Conditions. In addition to revising the criteria for shoulder surgery, this new guideline has been expanded to include diagnosis and non-operative treatment of shoulder conditions. It becomes effective on January 1, 2014.
The Shoulder Conditions Diagnosis and Treatment Guideline, along with all of the L&I treatment guidelines, can be found in the MTG section of the L&I website. The documents are listed in alphabetical order on the "Treatment Guidelines" page. Scroll down to find the "Shoulder Conditions Diagnosis and Treatment Guideline" document.
Qualis Health will begin using the updated Review Criteria for Shoulder Surgery (pages 2-6) on January 1, 2014.
For Group A providers, all shoulder surgery will require submission of chart notes for full clinical review until further notice. Please submit:
- Request for review form
- Physical examination
- Imaging reports
- Documentation of conservative care
- The document "Advanced Imaging Procedures Requiring UR Review” has been updated and is current as of July 2013.
- New Labor & Industries Opioid Prescribing Guidelines Effective July 1, 2013
Labor & Industries' new Guideline for Prescribing Opioids to Treat Pain in Injured Workers is effective July 1, 2013. The new guideline provides valuable information to help you improve treatment, including an important section on managing surgical pain in workers who are on chronic opioid therapy.
We encourage you to review the guideline and adopt its best practices. This will give you a head start on incorporating new requirements into your practice before the July 1 effective date.
For more information, please read the Provider Network Update.
Changes that may affect your practice:
- Providers should access the state's PMP and review the worker's controlled substance history to get accurate information on opioid dose and concurrent medication use.
- Long-acting opioids (e.g., OxyContin) will not be authorized for post-surgical pain unless the worker was maintained on the drug before surgery.
- In most cases, opioids should be tapered to pre-operative dose or lower by six weeks after surgery. Coverage beyond six post-surgery weeks will require authorization.
- Ulnar Nerve Transposition Surgeries to Require Full Clinical Review Effective June 1, 2013
Effective June 1, all requests for ulnar nerve transposition surgery (CPT code 64718) will require full clinical review for all providers, including Group A providers. Surgery requests must be submitted to Qualis Health following the standard Utilization Review (UR) process. Learn more about the UR process.
Please note the very specific requirements for the electrodiagnostic studies. In order to fulfill these requirements, two of the four elements must be met. Inching studies are rarely included in standard nerve conduction studies (NCS). The surgeon’s office may want to specifically request that a NCS include inching studies if cubital tunnel syndrome is suspected. View the medical treatment guidelines for ulnar nerve diagnosis and treatment.
- New Spinal Injection Review Questionnaires Effective February 1, 2013
Based on provider feedback, Washington L&I and Qualis Health have updated the spinal injection review questionnaires. Effective February 1, 2013, you must submit requests using the updated questionnaires.
Providers who fax requests can find the new questionnaires on the Provider Resources page. Submission of outdated questionnaires via fax will result in processing delays; only current questionnaire versions will be processed.
Providers who submit requests electronically using our web-based solution, iEXCHANGE®, will access the most recent version of the questionnaires. If you need assistance signing up for iEXCHANGE or have questions about web-based reviews, please call us at (800) 949-7536 ext. 2800 or email firstname.lastname@example.org.