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.
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.
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.
Changes that may affect your practice:
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.
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.
Effective January 1, 2013, providers must be in the Labor & Industries (L&I) Medical Provider Network (MPN) to treat injured workers (IW) beyond the initial office or emergency room visit. Providers who are IWs' attending providers must apply, and include physicians, chiropractors, naturopathic physicians, podiatric physicians, surgeons, dentists, optometrists, advanced registered nurse practitioners and physician assistants.
Providers can apply here. For referrals, see the directory of network providers. The directory is updated each business day, and the number of network providers is growing rapidly as L&I processes network applications. Visit the L&I FAQ webpage for commonly asked questions.
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.
Effective September 1, 2012, Washington L&I will implement a review program using the Health Technology Clinical Committee spinal injection coverage criteria. This change affects these CPT codes: 62310, 62311, 62318, 62319, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495 and 27096.
All spinal injections will require utilization review. To be approved, requests should meet the coverage criteria. Visit the Washington State L&I Authorizations and Referrals page for more information. Requests for authorization must be submitted via an iEXCHANGE® account. To create an iEXCHANGE® account, go to the One Health Port registration page and scroll to the bottom.
Visit the Qualis Health Provider Education page for the provider manual and informational videos. Additionally, spinal injection questionnaires, procedure codes and Qualis Health and L&I contact information are available on the Qualis Health Provider Resources page.