PHYSICIAN GUIDE TO SUBMITTING IMAGING REQUESTS FOR WASHINGTON MEDICAID PATIENTS

Effective October 1, 2011, physician practices that order certain advanced imaging studies for their Washington fee-for-service Medicaid patients will need to obtain online authorizations for those tests. Washington Medicaid has engaged Qualis Health to provide those utilization review services. Register or update your current profile through One Health Port for the ability to submit reviews for Washington Medicaid, even if you already submit reviews for Washington Labor and Industries Advanced Imaging that are reviewed by Qualis Health.

Please note the following new process:

• Only selected CPT codes are required for Qualis Health review.
• You should first confirm the patient’s medical coverage through WA Medicaid prior to submission.
• Eligibility issues for WA Medicaid patients must be determined by the provider by contacting the State at: http://hrsa.dshs.wa.gov/providerone/.
• The physician or designated personnel submits a review to Qualis Health through a web based, secure system; iEXCHANGE®.
• Physicians/practitioners log in through One Health Port.
• iEXCHANGE will collect basic patient information for those imaging procedures requiring pre-service review, as well as, completion of a medical necessity questionnaire embedded in the iEXCHANGE case.
• Qualis Health will forward completed reviews to WA Medicaid for final determination.
• WA Medicaid will fax final determination information to the requesting provider.
• There is no incentive for Qualis Health regarding the outcome of the utilization decision.

RECONSIDERATION PROCEDURES

Qualis Health has a procedure in place for providers to request a re-review for advanced imaging services:

• The physician or practitioner may request a re-review of the denial by fax.
• Complete the Advanced Imaging Request for Review form found on the Qualis Health website:
  http://wwww.qualishealth.org/healthcare-professionals/washington-medicaid/provider-resources.
• Please indicate the Qualis Health reference number (starting with 913…) for which the review is being requested.
• Please submit the form and last three months (if available) of clinical notes and related imaging reports to Qualis Health at (888) 213-7516.
• Upon receipt of a request for re-review, the Qualis Health staff will review documentation to determine if the request can be approved. If not, the request will be forwarded to a physician reviewer.
• The Qualis Health physician will review the medical information to determine if medical necessity criteria for the procedure are met.
• If the physician reviewer reverses the denial decision, Qualis Health will submit the determination to Washington Medicaid.
• If the physician reviewer upholds the denial determination, Qualis Health will notify the submitting practitioner via fax and offer the submitting practitioner a discussion with a Qualis Health physician. The submitting practitioner has 48 hours (two business days) to respond to this offer.
• Within two business days, the Qualis Health physician reviewer will finalize his/her decision. This determination will be sent to Washington Medicaid.
• If the provider still disagrees with the denial decision, he/she may request by fax for the case to be reviewed by a separate peer reviewer for final determination.

For further information, please visit www.qualishealth.org or call Qualis Health at (888) 213-7513.