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Spokane, WA (WorkersCompensation.com) -- In the State of Washington, the utilization review process compares requests for medical services treatment guidelines that are deemed appropriate for such services and includes the preparation of a recommendation based on that comparison.
Washington's utilization review program applies only to claims that are adjudicated by the State Fund. The program applies to both physicians and facilities.
The following chart breaks down how UR operates in Washington.
| Subjects | Rules in Wash. |
| What requires UR | + All inpatient hospitalizations. + Selected outpatient surgical procedures. + Physical medicine, PT, and OT after the 24th visit. + Advanced imaging studies. + Spinal injections. + UR simplification (Group A providers). |
| Group A providers | Providers do not apply for Group A status. Group A status is awarded based on a retroactive review of the previous year's surgical requests. |
| Criteria to determine Group A Status | + Providers must have submitted at least 10 UR requests during the evaluation period. Requests may be any combination of IP or OP procedures. Prover must have 100% approval on all UR requests. + Review period will be based on the previous 12 full months of data. + Providers must maintain 100% approval to remain Group A. |
| Compliance determination | 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. |
| Records availability | If a request is up for audit and the relevant clinical records are not available in the image file, the provider must supply records for audit or be subject to possible removal from Group A status. |
| Warnings | + Providers who are 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 a warning letter. + A 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. + Warning letters will be mailed to the provider notifying them of the focused audit or probationary status. |
| Focused audit | Focused audits 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. |
| Denial during audit or probation | Providers who receive a denial during the focused case audit or while on probationary status may be subject to removal of Group A status. |
| Cases allowed | + 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 1 year for all Group A providers. |
| How Group A providers request a procedure | Providers are required to submit an online notification using the OneHealthPort single sign-on page. |
| What must be included in request submissions | + 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. |
| About procedures | +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 | Audits will be performed retrospectively after submission of the request that may or may not be after the surgical procedure is performed or based on a Group A provider's performance. Auditing involves a clinical reviewer accessing the medical records to determine if the surgery as requested meets the applicable medical treatment guideline. 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. |
| UR Process | (1) Provider submits request via web portal, OneHealthPort. We mandate UR requests be web based. (2) For assistance with portal access, contact Comagine Health at 800-541-2894. (3) Comagine Health uses our Medical Treatment Guidelines, Health Technology Clinical Committee (HTCC) decisions and InterQual criteria to evaluate requested services. (4) If request meets guidelines or criteria, approval recommended. (5) If request does not meet guidelines or criteria, physician review is initiated. (6) 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. (7) Detailed clinical report is submitted to the Department. (8) Options for re-review are detailed in the Comagine communication to the provider and in the Department letters. |
| Final determination | The claim manager will issue the final determination and inform the requesting provider. |
| Noninitiated claims | + Comagine Health reviews requests for treatment or procedures for non-initiated claims in the same manner as initiated claims. + A determination may be delayed until the claim has been initiated and assigned to a claim manager. + The Office of the Medical Director (OMD) manages the UR contract. |
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About The Author
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Frank Ferreri
Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law. Frank encourages everyone to consider helping out the Kind Souls Foundation and Kids' Chance of America.
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