| Utilization Reviews (UR) |  | |
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.
