Wash. Admin. Code § 296-20-010

Current through Register Vol. 24-21, November 1, 2024

Section 296-20-010 - General information

(1) The following rules are promulgated pursuant to RCW 51.04.020 and 51.04.030. The department or self-insurer may purchase necessary physician and other provider services according to the fee schedules. The fee schedules shall be established in consultation with interested persons and updated at times determined by the department in consultation with those interested persons. Prior to the establishment or amendment of the fee schedules, the department will give at least thirty calendar days notice by mail to interested persons who have made timely request for advance notice of the establishment or amendment of the fee schedules. To request advance notice of the establishment or amendment of the fee schedules, interested persons must contact the department at the following address:

Department of Labor and Industries

Health Services Analysis

Interested Person's Mailing List for the Fee Schedules

P.O. Box 44322

Olympia, WA 98504-4322

As an alternative, interested persons may subscribe to the LI medical provider news listserv. To subscribe, go to the department's web site at www.lni.wa.gov and click on the link "Provider billing payment." Look for the icon that says "Get E-mail Updates" and click on it.

The department or self-insurer will require the current version of the federal Health Care Common Procedure Coding System (HCPCS) Level I (or CPT) and II codes on January 1st, of each new year. CPT refers to the American Medical Association's Physicians' Current Procedural Terminology codes.

The adoption of these codes on an annual basis is designed to reduce the administrative burden on providers and lead to more accurate reporting of services. However, the inclusion of a service, product or supply within these new codes does not necessarily imply coverage, reimbursement or endorsement, by the department or self-insurer. The department will make coverage and reimbursement decisions for these new codes on an individual basis.

If there are any services, procedures or narrative text contained in the new HCPCS Level I and II codes that conflict with the medical aid rules or fee schedules, the department's rules and policies take precedence.

Copies of the HCPCS Level I and II codes are available for public inspection. These documents are available in each of the department's service locations.

Copies of the HCPCS Level II codes may be purchased from:

The Superintendent of Documents

United States Government Printing Office

Washington, DC 20402 202-783-3238

Copies of the Level I (or CPT) codes may be purchased from:

The American Medical Association

Chicago, Illinois 60601 800-621-8335

In addition to the sources listed above, both the Level I and II codes may be purchased from a variety of private sources.

(2) The fee schedules are intended to cover all services for accepted industrial insurance claims. All fees listed are the maximum fees allowable. Practitioners shall bill their usual and customary fee for services. If a usual and customary fee for any particular service is lower to the general public than listed in the fee schedules, the practitioner shall bill the department or self-insurer at the lower rate. The department or self-insurer will pay the lesser of the billed charge or the fee schedules' maximum allowable.

(3) The rules contained in the introductory section pertain to all practitioners regardless of specialty area or limitation of practice. Additional rules pertaining to specialty areas will be found in the appropriate section of the medical aid rules.

(4) The methodology for making conversion factor cost of living adjustments is listed in WAC 296-20-132. The conversion factors are listed in WAC 296-20-135.

(5) L&I or self-insurers will not pay for a missed appointment unless the appointment is for an examination arranged by the department or self-insurer.

(6) Other than missed appointments for examinations arranged by the department or self-insurer, a provider may bill an injured worker for a missed appointment if:

(a) The provider has a missed appointment policy that applies to all patients without regard as to which insurer or entitlement program may be responsible for payment; and

(b) The provider routinely notifies all patients of the missed appointment policy.

The implementation and enforcement of the policy is a matter between the provider and the injured worker. L&I is not responsible for the implementation and/or enforcement of the provider's policy.

(7) When a claim has been accepted by the department or self-insurer, no provider or his/her representative may bill the worker for the difference between the allowable fee and the usual and customary charge. Except for missed appointment fees under subsection (6) of this section, the worker may not be charged a fee, either for interest or completion of forms, related to services for the industrial injury or condition.

(8) Practitioners must maintain documentation in claimant medical or health care service records adequate to verify the level, type, and extent of services provided to claimants. A health care practitioner's bill for services, appointment book, accounting records, or other similar methodology do not qualify as appropriate documentation for services rendered. Refer to chapter 296-20 WAC and department policy for reporting requirements.

(9) Except as provided in WAC 296-20-055 (Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery), practitioners shall bill, and the department or self-insurer shall pay, only for proper and necessary medical care required for the diagnosis and curative or rehabilitative treatment of the accepted condition.

(10) When a worker is being treated concurrently for an unrelated condition the fee allowable for the service(s) rendered must be shared proportionally between the payors.

(11) Correspondence: Correspondence pertaining to state fund and department of energy claims should be sent to: Department of Labor and Industries, Claims Administration, P.O. Box 44291, Olympia, Washington 98504-4291.

Accident reports should be sent to: Department of Labor and Industries, P.O. Box 44299, Olympia, Washington 98504-4299.

Send all provider bills and adjustments to: Department of Labor and Industries, P.O. Box 44269, Olympia, Washington 98504-4269.

State fund claims have six digit numbers or a letter and five digits preceded by a letter other than "S," "T," or "W."

All correspondence and billings pertaining to crime victims claims should be sent to Crime Victims Division, Department of Labor and Industries, P.O. Box 44520, Olympia, Washington 98504-4520.

Crime victim claims have six digit numbers preceded by a "V" or five digit numbers preceded by "VA," "VB," "VC," "VH," "VJ," or "VK."

All correspondence and billings pertaining to self-insured claims should be sent directly to the employer or the service representative as the case may be.

Self-insured claims are six digit numbers or a letter and five digits preceded by an "S," "T," or "W."

Communications to the department or self-insurer must show the patient's full name and claim number. If the claim number is unavailable, providers should contact the department or self-insurer for the number, indicating the patient's name, Social Security number, the date and the nature of the injury, and the employer's name. A communication should refer to one claim only. Correspondence must be legible and reproducible, as department records are microfilmed. Correspondence regarding specific claim matters should be sent directly to the department in Olympia or self-insurer in order to avoid rehandling by the service location.

(12) The department's various local service locations should be utilized by providers to obtain information, supplies, or assistance in dealing with matters pertaining to industrial injuries.

Wash. Admin. Code § 296-20-010

Statutory Authority: RCW 51.04.020. 12-05-098, § 296-20-010, filed 2/21/12, effective 3/23/12. Statutory Authority: RCW 51.04.020, 51.36.080, 7.68.030, 7.68.080. 07-08-088, § 296-20-010, filed 4/3/07, effective 5/23/07. Statutory Authority: RCW 51.04.020. 05-09-063, § 296-20-010, filed 4/19/05, effective 7/1/05; 03-21-069, § 296-20-010, filed 10/14/03, effective 12/1/03. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 96-10-086, § 296-20-010, filed 5/1/96, effective 7/1/96. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-14-044, § 296-20-010, filed 6/29/94, effective 7/30/94; 93-16-072, § 296-20-010, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 92-24-066, § 296-20-010, filed 12/1/92, effective 1/1/93; 90-04-057, § 296-20-010, filed 2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), § 296-20-010, filed 11/30/87, effective 1/1/88; 86-20-074 (Order 86-36), § 296-20-010, filed 10/1/86, effective 11/1/86; 86-06-032 (Order 86-19), § 296-20-010, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), § 296-20-010, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-010, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-010, filed 12/23/80, effective 3/1/81; Order 76-34, § 296-20-010, filed 11/24/76, effective 1/1/77; Order 75-39, § 296-20-010, filed 11/28/75, effective 1/1/76; Order 74-7, § 296-20-010, filed 1/30/74; Order 70-12, § 296-20-010, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-010, filed 11/27/68, effective 1/1/69.