reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-600 - How does an eligible injured worker elect vocational Option 2 benefits?

Current through Register Vol. 24-14, July 15, 2024
(1) If the worker's
				plan was approved prior to July 31, 2015, the worker has up to fifteen days
				from the approval of a retraining plan or the department's determination that a
				disputed plan is valid to submit to the department or self-insured employer the
				retraining plan option election form indicating they elect Option 2 and choose
				not to participate in their retraining plan.
(2) If the worker's plan was approved on or
				after July 31, 2015, the worker can elect Option 2 at any point within the
				following time period:
* Beginning with the date of plan approval or the
				  department's determination that a disputed plan is valid; and
* Ending the fifteenth day after completion of the first
				  academic quarter or three months' training.
(a)To elect Option 2, the worker submits to
				the department or self-insured employer the retraining plan option election
				form indicating they elect Option 2 and choose not to participate, or continue
				participating, in their retraining plan.
(b)Wherever the time for electing Option 2 is
				referenced in chapter 296-19A WAC, if the school or training program does not
				use an academic quarter system, the three-month time period applies; however,
				if the worker's vocational retraining plan is less than three months in
				duration, the worker's last day to elect Option 2 is the day before the plan
				ends. The worker cannot elect Option 2 after the plan is completed.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-610 - What is a vocational Option 2 award?

Current through Register Vol. 24-14, July 15, 2024
(1) If the worker's plan was approved prior
				to July 31, 2015, the vocational Option 2 award is equivalent to six months of
				temporary total disability compensation.
(2)If the worker's plan was approved on or
				after July 31, 2015, the vocational Option 2 award is equivalent to nine months
				of temporary total disability compensation.
(3) The vocational Option 2 award is based on
				the worker's monthly compensation rate on the date the Option 2 benefit is
				granted. The award will be paid to the worker in biweekly payments until the
				award is paid in full.
(4) Whenever
				the biweekly payments are made over a period that includes July 1, the amount
				of the payment(s) will include any cost-of-living adjustment.
(5)The temporary total disability amount used
				will not include any adjustments for the worker's receipt of Social Security
				benefits.
(6) The department or
				self-insured employer will deduct any overpayments owed from the vocational
				Option 2 award.
Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-610, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-620 - What are the vocational Option 2 training funds?

Current through Register Vol. 24-14, July 15, 2024
(1) These training funds are available to the
				worker, upon application to the department or self-insured employer, for a
				period of five years following the date of the department's order confirming
				the worker's Option 2 election.
(2)
				The funds can be used to participate in any training through an accredited,
				licensed, or department-approved training program or institution.
(3) The worker can use the training funds for
				tuition, books, fees, supplies, equipment, and tools. In addition, if the
				worker's plan was approved on or after July 31, 2015, the worker can use up to
				ten percent of the training funds for vocational counseling and job placement
				services.
(4) Eligible workers are
				notified of the training fund amount by department order issued at the time of
				their Option 2 election.
Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-620, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-625 - What if an eligible worker elects Option 2 after starting the retraining plan?

Current through Register Vol. 24-14, July 15, 2024
(1) If the worker's
				plan was approved on or after July 31, 2015, the worker can elect Option 2 at
				any point within the following time period:
* Beginning with the date of plan approval or the
				  department's determination that a disputed plan is valid; and
* Ending the fifteenth day after completion of the first
				  academic quarter or three months' training.
(2) However, if the worker specified in
				subsection (1) of this section elects Option 2 after starting the Option 1
				retraining plan the following will occur:
(a)The training funds will be reduced by the
				amount of tuition and related charges expended during the Option 1 retraining
				plan; and
(b)The nine-month
				vocational Option 2 award will be reduced by the amount the worker was paid for
				time-loss days starting with the first date of Option 1 retraining through the
				date the department received the worker's Option 2 election.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-627 - If the worker has more than one open claim and is approved for vocational retraining, can the worker pick Option 1 on one claim and Option 2 on the other?

Current through Register Vol. 24-14, July 15, 2024
No. If a worker has more than one open claim and is found to
				  be eligible for plan development services based on the effects of all injuries
				  or illnesses related to the claim(s), the assigned vocational provider will
				  develop one plan for the worker that takes into account the restrictions caused
				  by all of the worker's accepted conditions. Once the department approves that
				  plan, the worker will be given an option election form that allows the worker
				  to choose to perform the plan that was developed for the worker (Option 1) or
				  to choose Option 2. The worker's election of an option on that form will apply
				  to all the claims under which the retraining plan was developed, regardless of
				  whether the claim(s) are state fund or covered under a self-insured
				  employer.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-629 - After the worker has elected Option 2, can the worker elect Option 1?

Current through Register Vol. 24-14, July 15, 2024
No. The worker cannot elect Option 1 after the department
				  has issued the order confirming the worker's Option 2 election. Exception: A
				  worker may elect Option 1 when the Option 2 election has been rescinded as
				  provided by
				  RCW
				   51.32.096(4)(b).
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-630

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-630, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-631 - What are Option 2 vocational counseling and job placement services?

Current through Register Vol. 24-14, July 15, 2024
(1) Option 2 allows
				workers access to training funds for self-directed training plans. Up to ten
				percent of the worker's available training funds may be used for vocational
				counseling and job placement services if both the following are true:
(a) The worker's plan was approved on or
				after July 31, 2015; and
(b) The
				department has granted Option 2 benefits to the worker.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-633 - Who can deliver Option 2 vocational counseling and job placement services?

Current through Register Vol. 24-14, July 15, 2024
(1) A vocational
				rehabilitation counselor who meets the qualifications in WAC
				296-19A-210(1)
				 and obtains a provider number issued by the department can deliver Option 2
				vocational counseling and job placement services. Interns cannot deliver Option
				2 vocational counseling and job placement services.
(2) A public sector organization that
				provides such services, such as WorkSource.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-635 - Who pays the vocational provider for Option 2 vocational counseling and job placement services?

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				or self-insured employer will pay for appropriately submitted billings from the
				worker's Option 2 training fund, within the following limits:
(a) The total of all payments for all Option
				2 vocational counseling and job placement services will not exceed ten percent
				of the worker's maximum Option 2 training fund, nor will the payment or
				payments for Option 2 vocational counseling and job placement services exceed
				the remaining balance of the worker's maximum Option 2 training fund at the
				time payment is made; and
(b)
				Vocational services must be provided within five years following the date of
				the department's order confirming the worker's Option 2 election.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-637 - How are vocational counseling and job placement services delivered?

Current through Register Vol. 24-14, July 15, 2024
(1) Beginning the
				date Option 2 benefits are granted, the worker can enlist the services of a
				qualified vocational rehabilitation provider.
(a) The worker and vocational provider must
				create a service agreement focused on the worker's goals. The agreement must
				clearly state:
(i) The worker's vocational
				goals.
(ii) The list of planned
				vocational services.
(iii) The
				worker's and vocational provider's responsibilities in fulfilling the
				agreement.
(iv) The total estimated
				hours and cost of planned services.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-640 - What costs cannot be paid from the vocational Option 2 training funds?

Current through Register Vol. 24-14, July 15, 2024
Training funds cannot be used for ergonomic equipment, prejob
				  accommodations, job modifications, on-the-job training, self-employment,
				  lodging or transportation.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-640, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-650 - Is the vocational Option 2 award paid if the worker is confined in an institution and under sentence?

Current through Register Vol. 24-14, July 15, 2024
No. The department or self-insured employer will pay the
				  balance of the Option 2 award when notified in writing the worker is no longer
				  confined and under sentence.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-650, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-660 - Can a worker use the vocational Option 2 training funds if confined in an institution and under sentence?

Current through Register Vol. 24-14, July 15, 2024
Yes. Vocational Option 2 training funds are available to the
				  worker, upon application to the department or self-insurer.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-660, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-19A - Vocational rehabilitation › OPTION 2 BENEFITS › Section 296-19A-670 - If a worker dies while receiving the vocational Option 2 award, will the award be paid to the worker's beneficiaries or estate?

Current through Register Vol. 24-14, July 15, 2024
No. The vocational Option 2 award is not payable to the
				  worker's beneficiaries or estate.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.32.095,
					 51.32.099 and
					 51.32.0991 (2007 c 72). 10-07-054,
					 § 296-19A-670, filed 3/12/10, effective
					 4/12/10.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-0100 - Industrial insurance chiropractic advisory committee

Current through Register Vol. 24-14, July 15, 2024
(1)
(a) The
			 director shall appoint an industrial insurance chiropractic advisory committee
			 (committee) composed of up to nine members licensed to practice chiropractic in
			 Washington from the nominations provided by statewide associations.
(b) At least two of the total nine members
			 must be chiropractors who are recognized for expertise in evidence-based
			 practice or occupational health, or both.
(c) To the extent possible, all members shall
			 have experience or knowledge of treating injured workers or evidence-based
			 practice, or both.
(d) The director
			 may, at his or her discretion, exclude or remove any nominee, committee member,
			 or hired expert if the person does not meet a condition of appointment,
			 including but not limited to:
(i) Having, or
			 failing to disclose, a conflict of interest;
(ii) Breaching a statute, rule, or the
			 committee's bylaws, including a quality of care concern or professional related
			 action alleged by a government agency; or
(iii) If the committee or committee chair
			 recommends removal for good cause shown.
(e) Appointments to the committee shall be up
			 to three year terms, which the department may renew.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01001 - Industrial insurance medical advisory committee

Current through Register Vol. 24-14, July 15, 2024
(1)
(a) The
			 director shall appoint an industrial insurance medical advisory committee
			 (committee) composed of up to fourteen members.
(b) The appointments shall include twelve
			 members from the nominations provided by statewide clinical groups,
			 specialties, and associations and shall be consistent with the specialty types
			 required by law.
(c) At least two
			 of the total fourteen members must be physicians who are recognized for
			 expertise in evidence-based medicine.
(d) The director may choose up to two of the
			 fourteen members, not necessarily from the nominations submitted, who have
			 expertise in occupational medicine.
(e) To the extent possible, members shall be
			 chosen from nominees with experience or knowledge of treating injured workers
			 or evidence-based medicine, or both.
(f) The director may, at his or her
			 discretion, exclude or remove any nominee, committee member, or hired expert if
			 the person does not meet a condition of appointment, including but not limited
			 to:
(i) Having, or failing to disclose, a
			 conflict of interest;
(ii)
			 Breaching a statute, rule, or the committee's bylaws, including a quality of
			 care concern or professional related action alleged by a government agency;
			 or
(iii) If the committee or
			 committee chair recommends removal for good cause shown.
(g) Appointments to the committee shall be up
			 to three year terms, which the department may renew.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01010 - Scope of health care provider network

Current through Register Vol. 24-14, July 15, 2024
(1) The rules establish the development,
			 enrollment, and oversight of a network of health care providers approved to
			 treat injured workers. The health care provider network rules apply to care for
			 workers covered by Washington state fund and self-insured employers.
(2) As of January 1, 2013, the following
			 types of health care providers (hereafter providers) must be enrolled in the
			 network with an approved provider agreement to provide and be reimbursed for
			 care to injured workers in Washington state beyond the initial office or
			 emergency room visit:
(a) Medical physicians
			 and surgeons;
(b) Osteopathic
			 physicians and surgeons;
(c)
			 Chiropractic physicians;
(d)
			 Naturopathic physicians;
(e)
			 Podiatric physicians and surgeons;
(f) Dentists;
(g) Optometrists;
(h) Advanced registered nurse practitioners;
			 and
(i) Physician
			 assistants.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01030 - Minimum health care provider network standards

Current through Register Vol. 24-14, July 15, 2024
The department will deny an application if a provider does not
				meet minimum health care provider network standards. To be eligible for
				enrollment and participation in the provider network, a provider must meet and
				maintain the following minimum health care provider network standards:
(1) The provider must submit an accurate and
			 complete provider application, including any required supporting documentation
			 and sign without modification, a provider agreement with the
			 department.
(2) The provider must
			 have current professional liability coverage, individually or as a member of a
			 group, through a commercial carrier or provide documentation of self-insurance.
(a) Professional liability coverage must be
			 at least in the amounts of one million dollars per occurrence and three million
			 dollars annual aggregate; or in the amounts otherwise published by the
			 department for the provider type's scope of practice, after notice and
			 opportunity for comment.
(b)
			 Providers in a group practice who are self-insured for professional liability
			 coverage must provide evidence that liabilities in amounts at least equivalent
			 to liability limits in (a) of this subsection are booked on audited financial
			 statements in accordance with generally accepted accounting
			 standards.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01040 - Health care provider network continuing requirements

Current through Register Vol. 24-14, July 15, 2024
To continue to provide care for workers and be paid for those
				services, a provider must:
(1) Provide
			 services without unlawful discrimination;
(2) Provide services and bill according to
			 federal and state laws and rules, department rules, policies, and billing
			 instructions;
(3) Maintain material
			 compliance with minimum provider network standards, department credentialing
			 and recredentialing standards, and department's evidence-based coverage
			 decisions and treatment guidelines, policies; and must follow other national
			 treatment guidelines appropriate for their patient;
(4) Inform the department or an applicable
			 delegated credentialing entity of any material changes to the provider's
			 application or agreement within fourteen calendar days including, but not
			 limited to, changes in:
(a) Ownership or
			 business name;
(b) Address or
			 telephone number;
(c) Professionals
			 practicing under the billing provider number;
(d) Any informal or formal disciplinary
			 order, decision, disciplinary action or other action(s), including any criminal
			 action, in any state;
(e) Provider
			 clinical privileges;
(f)
			 Malpractice claims or professional liability coverage;
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01050 - Health care provider network further review and denial

Current through Register Vol. 24-14, July 15, 2024
(1) The department
			 may further review a complete provider application based on information within
			 the application or credentialing information obtained from other
			 sources.
(2) For complete
			 applications requiring further review, the department's medical director or
			 designee has the authority to approve or deny consistent with department rules
			 and policies, and may seek advice, expertise, consultation or recommendations
			 on applications from:
(a) Peer or clinical
			 review individuals or entities;
(b)
			 The industrial insurance medical or chiropractic advisory committee (including
			 a subcommittee);
(c) A department
			 appointed credentialing committee.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01060 - Delegation of credentialing and recredentialing activities

Current through Register Vol. 24-14, July 15, 2024
(1) The department
			 may delegate credentialing and recredentialing review activities to the
			 following entities:
(a) Medical and dental
			 group(s) and clinics;
(b) Physician
			 organizations;
(c) Credentials
			 verification organizations (CVOs); or
(d) Other organizations that employ and/or
			 contract with providers.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01070 - Waiting periods for reapplying to the network

Current through Register Vol. 24-14, July 15, 2024
(1) Providers are not eligible to reapply for
			 enrollment in the network if they have been denied or removed from network
			 participation due to:
(a) A finding of risk of
			 harm, pursuant to WAC
			 296-20-01100;
(b) Having been excluded, expelled or
			 suspended, other than for convenience, from any federally or state funded
			 programs including, but not limited to, medicare or medicaid
			 programs;
(c) Having been convicted
			 of a felony or pled guilty to a felony for a crime and the felony has not been
			 expunged from the provider's record including, but not limited to, health care
			 fraud, patient abuse and the unlawful manufacture, distribution, prescription
			 or dispensing of controlled substances;
(d) Sexual misconduct as defined in
			 profession specific rules of any state or jurisdiction, including Washington
			 state department of health.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01080 - Management of the provider network

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Appropriate action(s) by the department to monitor quality of care and assure
			 efficient management of the provider network may include, but are not limited
			 to:
(a) Monitoring the provider;
(b) Mentoring the provider;
(c) Restricting payment for services rendered
			 by the provider;
(d) Suspending the
			 provider from the network; or
(e)
			 Removing the provider from the network.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01090 - Request for reconsideration of department decision

Current through Register Vol. 24-14, July 15, 2024
(1) A provider may request reconsideration of
			 the department's decision to deny enrollment or remove or suspend a provider
			 from the health care provider network. The request for reconsideration must be
			 received by the department within sixty calendar days from the date the
			 department's decision is communicated to the provider.
(2) A provider must:
(a) Specify the department decision(s) that
			 the provider is disputing;
(b)
			 State the basis for disputing the department's decision; and
(c) Include documentation to support the
			 provider's position.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01100 - Risk of harm

Current through Register Vol. 24-14, July 15, 2024
(1) It is the
			 intent of the department, through authority granted by
			 RCW
			  51.36.010 to protect workers from physical or
			 psychiatric harm by identifying, and taking appropriate action, including
			 removal of providers from the statewide network, when:
(a) There is
harm
; and
(b) There is a
pattern(s)
of
low quality care;
and
(c) The harm is related to the pattern(s) of
			 low quality care.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-015 - Who may treat

Current through Register Vol. 24-14, July 15, 2024
To treat workers under the Industrial Insurance Act, a health
				care provider must qualify as an approved provider under the department's
				rules. The department must approve the health care provider before the health
				care provider is eligible for payment for services.
(1) A provider must:
(a) Apply and be enrolled in the provider
			 network per WAC
			 296-20-01010; or
(b) If the provider network scope in WAC
			 296-20-01010 is not applicable,
			 apply and obtain a provider account number per WAC
			 296-20-12401.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01501 - Physician's assistant rules

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Physician assistants (PA) may be "treating providers" pursuant to WAC
			 296-20-01002, under the workers'
			 compensation system, and they may be approved for payment for those medical
			 services for which the physician assistant is trained and licensed, under the
			 control and supervision of a licensed physician. Such control and supervision
			 shall not be construed to require the personal presence of the supervising
			 physician.
(2) Physician assistants
			 may perform those medical services which are within the scope of their
			 physician's assistant license within the limitations of subsection (3) of this
			 section.
(3) To be eligible to
			 treat and be paid for workers' compensation related services, the physician
			 assistant must obtain a provider number by:
(a) Providing the department with a copy of
			 his/her license;
(b) Providing the
			 name, address, specialty, and provider number issued by the department of the
			 supervising physician(s) on the provider application (a PA may have to obtain
			 more than one provider number if billing under multiple supervising
			 physicians); and
(c) Notifying the
			 department of any change of the parameters listed in (a) or (b) of this
			 subsection.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-01505 - Provider types and services not covered

Current through Register Vol. 24-14, July 15, 2024
The department will not pay for services performed by the
				following practitioners:
Herbalists
Christian Science practitioners or theological healers
Homeopathists
Noncertified physician assistants
Operating room technicians
Certified surgical technicians
Certified surgical assistants
Any other licensed or unlicensed practitioners not otherwise
				specifically provided for by the department.
Statutory Authority:
				  RCW
				   51.04.020,
				  51.04.030 and 1993 c 159.
				  94-14-044, § 296-20-01505, filed 6/29/94, effective
				  7/30/94.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-020 - Acceptance of rules and fees

Current through Register Vol. 24-14, July 15, 2024
The filing of an accident report or the rendering of treatment
				to a worker who comes under the department's or self-insurer's jurisdiction, as
				the case may be, constitutes acceptance of the department's medical aid rules
				and compliance with its rules and fees.
In accordance with
				RCW
				 51.28.020 of the industrial insurance law,
				when a doctor renders treatment to a worker entitled to benefits under the law,
				"it shall be the duty of the physician to inform the worker of his rights under
				this title and to lend all necessary assistance in making the application for
				compensation and such proof of other matters as required by the rules of the
				department without charge to the worker," a worker shall not be billed for
				treatment rendered for his accepted industrial injury or occupational
				disease.
The department or self-insurer must be notified immediately,
				when an unrelated condition is being treated concurrently with an industrial
				injury. See WAC
				296-20-055 for specific
				information required.
When there is questionable eligibility, (i.e., service is not
				usually allowed for industrial injuries or investigation is pending, etc.) the
				provider may require the worker to pay for the treatment rendered.
In cases of questionable eligibility where the provider has
				billed the worker or other insurance, and the claim is subsequently allowed,
				the provider shall refund the worker or insurer in full and bill the department
				or self-insurer for services rendered using billing instructions, codes, and
				policies as listed in the medical aid rules and fee schedules.
Cases in which there is a question of medical ethics or quality
				of medical care, will be referred to the Washington state medical association's
				medical advisory and utilization review committee to the department of labor
				and industries for recommendations.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030 and 1993 c 159.
				  93-16-072, § 296-20-020, filed 8/1/93, effective 9/1/93. Statutory
				  Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 86-06-032 (Order
				  86-19), § 296-20-020, filed 2/28/86, effective 4/1/86. Statutory
				  Authority:
				  RCW
				   51.04.020(4),
				  51.04.030, and
				  51.16.120(3).
				  81-01-100 (Order 80-29), § 296-20-020, filed 12/23/80, effective 3/1/81;
				  Order 76-34, § 296-20-020, filed 11/24/76, effective 1/1/77; Order 75-39,
				  § 296-20-020, filed 11/28/75, effective 1/1/76; Order 74-39, §
				  296-20-020, filed 11/22/74, effective 1/1/75; Order 71-6, § 296-20-020,
				  filed 6/1/71; Order 70-12, § 296-20-020, filed 12/1/70, effective 1/1/71;
				  Order 68-7, § 296-20-020, filed 11/27/68, effective
				  1/1/69.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-02005 - Keeping of records

Current through Register Vol. 24-14, July 15, 2024
A health services provider who requests from the department
				payment for providing services shall maintain all records necessary for the
				director's authorized auditors to audit the provision of services. A provider
				shall keep all records necessary to disclose the extent of services the
				provider furnishes to industrially injured workers. At a minimum, these records
				must provide and include prompt and specific documentation of the level and
				type of service for which payment is sought. Records must be maintained for
				audit purposes for a minimum of five years.
Statutory Authority:
				  RCW
				  51.04.020(4) and
				  51.04.030. 86-20-074 (Order
				  86-36), § 296-20-02005, filed 10/1/86, effective
				  11/1/86.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-02010 - Review of health services providers

Current through Register Vol. 24-14, July 15, 2024
(1) The department may review providers'
			 patient and billing related records to ensure workers are receiving proper and
			 necessary medical care and to ensure providers' compliance with the
			 department's medical aid rules, fee schedules, and policies. A records review
			 may be the basis for corrective action against the provider.
(2) The department may review records before,
			 during, or after delivery of health services. Records reviews may be for cause
			 or at random and may include the utilization of statistical sampling
			 methodologies and projections based upon sample findings. Records reviews may
			 be conducted at or away from the provider's places of business, at the
			 department's discretion.
(3) The
			 department will give ten working days' written notification to any provider
			 that the provider's patient and billing related records will be reviewed by an
			 auditor at the provider's place(s) of business to determine compliance with
			 medical aid rules and standards.
(4) The department may request legible copies
			 of providers' records. Providers shall furnish copies of the requested records
			 within thirty calendar days of receipt of the request.
(5) The department will not remove original
			 records from provider's premises.
(6) For information regarding the formal
			 appeals process refer to chapter 51.52 RCW.
Statutory Authority:
				  RCW
				  51.04.020. 03-21-069, § 296-20-02010,
				  filed 10/14/03, effective 12/1/03. Statutory Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 90-04-057, §
				  296-20-02010, filed 2/2/90, effective 3/5/90; 86-20-074 (Order 86-36), §
				  296-20-02010, filed 10/1/86, effective
				  11/1/86.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-02015 - Interest on excess payments

Current through Register Vol. 24-14, July 15, 2024
(1)
			 When a provider of health services receives a payment to which that provider is
			 not entitled, the provider must repay the excess payment, plus accrued
			 interest, without regard to whether the excess payment occurred due to provider
			 or department error or oversight, except as provided in subsection (2) of this
			 section.
(2) When a provider:
(a) Accepts in good faith a determination by
			 the department that a worker is eligible for benefits under
			 Title
			 51 RCW;
(b) Provides, bills, and receives payment for
			 services to that worker and the department later determines that the worker was
			 ineligible for services during that period no interest will begin to accrue
			 until notification is received by the provider that the worker was
			 ineligible.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-022 - Payment of out-of-state providers

Current through Register Vol. 24-14, July 15, 2024
(1)
How will health care providers outside of Washington state be
			 paid?
All health care service providers, regardless of their geographic
			 location, will be paid according to the fee schedule rules, rates, coverage and
			 payment policies as published in the Washington state
Medical Aid Rules
			 and Fee Schedules
and/or provider bulletins.
(2)
Can an injured worker be charged
			 for services?
In all cases, the department's maximum allowed fees and
			 payment levels are the maximum payable. If a provider's charge exceeds the
			 maximum amount payable under the department's
Medical Aid Rules and Fee
			 Schedules
, the provider must not charge the injured worker for the
			 difference. A provider violating this provision may be held ineligible to treat
			 injured workers as provided by department rules and may be subject to other
			 applicable penalties.
Exception:
When a provider treats an injured worker for
							 condition(s) unrelated to the worker's accepted industrial injury or illness,
							 the provider may bill the worker or other insurers for the unrelated services
							 only.
(3)
What services will be paid to providers outside of Washington?
Only those diagnostic and treatment services authorized under the state of
			 Washington medical aid rules, fee schedules, payment policies, or medical
			 coverage decisions may be authorized or paid by the department or self-insurer.
			 As determined by the department of labor and industries, the scope of practice
			 of providers outside the state of Washington may be recognized for payment
			 purposes. However, in all cases WAC
			 296-20-03002 (Treatment not
			 authorized) shall apply. Specifically, services not authorized under Washington
			 workers compensation rules, fee schedules, payment policies, or medical
			 coverage decisions will not be paid, even if permitted under the workers
			 compensation program in the provider's state or country of business. When in
			 doubt, the provider should verify coverage of a service with the department or
			 self-insurer.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.36.080. 00-09-078, §
				  296-20-022, filed 4/18/00, effective 7/1/00. Statutory Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 90-04-057, §
				  296-20-022, filed 2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), §
				  296-20-022, filed 11/30/87, effective 1/1/88; 87-03-004 (Order 86-45), §
				  296-20-022, filed 1/8/87.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-023 - Third party settlement - Excess recoveries

Current through Register Vol. 24-14, July 15, 2024
(1) In cases where a third-party settlement
			 has been made resulting in an excess recovery subject to offset from the
			 worker's future benefits or compensation due, the department or self-insurer is
			 not liable for payment for services rendered by providers.
(2) The worker should be treated and billed
			 in accordance with the department's medical aid rules and maximum fee
			 schedules. When bills are processed against the amount of the excess recovery,
			 the department will notify the provider on the remittance advice.
(3) The department or self-insurer will
			 resume financial responsibility to or on behalf of the worker when the amount
			 of such excess has been reduced to zero.
Statutory Authority: Chapters 51.04, 51.08,
				  51.12, 51.24 and
				  51.32 RCW and 117 Wn.2d 122 and 121
				  Wn.2d 304. 93-23-060, § 296-20-023, filed 11/15/93, effective 1/1/94.
				  Statutory Authority:
				  RCW
				   51.04.020(4) and
				  51.04.030. 86-06-032 (Order
				  86-19), § 296-20-023, filed 2/28/86, effective
				  4/1/86.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-024 - Utilization management

Current through Register Vol. 24-14, July 15, 2024
The department, as a trustee of the medical aid fund, has a
				duty to supervise the provision of proper and necessary medical care that is
				delivered promptly, efficiently, and economically. Toward this end, the
				department will institute programs of utilization management. These programs
				are designed to monitor and control the proper and necessary use and cost of,
				health care services. These programs include, but are not limited to, managed
				care contracting, prior authorization for services, and alternative
				reimbursement systems.
Statutory Authority:
				  RCW
				  51.04.020(4) and
				  51.04.030. 90-04-057, §
				  296-20-024, filed 2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), §
				  296-20-024, filed 11/30/87, effective
				  1/1/88.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-025 - Initiating treatment and submitting a claim for benefits

Current through Register Vol. 24-14, July 15, 2024
(1) Worker's responsibility: The worker must
			 notify the provider when the worker has reason to believe his/her injury or
			 illness is work related. If treatment beyond the initial office or emergency
			 room visit is needed, the worker must seek treatment from a network
			 provider.
(2) Provider's
			 responsibility: The provider must notify the worker if he/she identifies an
			 injury, illness, or condition which he/she has reason to believe is work
			 related.
Once such determination is made by either the worker or the
				attending provider, a report of the injury or illness must be filed with the
				department or self-insurer.
Failure to comply with this responsibility can result in
				penalties as outlined in
				RCW
				 51.48.060.
(3) Additional provider responsibilities: The
			 provider must ascertain whether he/she is the first attending provider and give
			 emergency treatment.
The first attending provider must immediately complete and
				forward a report of the injury or illness to the department or self-insurer and
				instruct and assist the injured worker in completing his/her portion of the
				report of the injury or illness. In filing a claim, the following information
				is necessary so there is no delay in adjudication of the claim or payment of
				compensation.
(a) Complete history of
			 the work related accident or exposure.
(b) Complete listing of positive physical
			 findings.
(c) Specific diagnosis
			 with the current federally adopted ICD-CM code(s) and narrative definition
			 relating to the injury.
(d) Type of
			 treatment rendered.
(e) Known
			 medical, emotional or social conditions which may influence recovery or cause
			 complications.
(f) Estimate
			 time-loss due to the injury or illness.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02700 - What is a medical coverage decision?

Current through Register Vol. 24-14, July 15, 2024
A medical coverage decision is a general policy decision by
				  the director or the director's designee to include or exclude a specific health
				  care service or supply as a covered benefit. These decisions are made to insure
				  quality of care and prompt treatment of workers. Medical coverage decisions
				  include, but are not limited to, decisions on health care services and supplies
				  rendered for the purpose of diagnosis, treatment or prognosis, such as:
Ancillary services including, but not limited to, home health
				  care services, ambulatory services, specific rehabilitative modalities;
Devices;
Diagnostic tests;
Drugs, biologics, and other therapeutic modalities;
Durable medical equipment;
Procedures;
Prognostic tests; and
Supplies.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-037, §
					 296-20-02700, filed 12/7/99, effective
					 1/8/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02701 - Who makes medical coverage decisions?

Current through Register Vol. 24-14, July 15, 2024
The director or the director's designee makes medical
				  coverage decisions.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-037, §
					 296-20-02701, filed 12/7/99, effective
					 1/8/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02702 - Who uses medical coverage decisions?

Current through Register Vol. 24-14, July 15, 2024
Self-insured employers and state fund claim managers use
				  medical coverage decisions to help them make claim-specific decisions. For
				  example, the director or director's designee may find that a particular medical
				  device is effective in treating a specific category of injuries. The medical
				  coverage decision might be that that device is a covered benefit for that
				  category of injuries. The self-insured employer or state fund claim manager
				  would make a claim-specific decision to pay or deny payment for that device
				  based on a number of factors, one of which is whether the accepted condition on
				  that claim matches the approved category of injuries in the medical coverage
				  decision.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-037, §
					 296-20-02702, filed 12/7/99, effective
					 1/8/00.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › MEDICAL COVERAGE DECISIONS › Section 296-20-02703 - How can I determine if a specific health care service or supply is the subject of a medical coverage decision?

Current through Register Vol. 24-14, July 15, 2024
(1) The
Medical Aid Rules
,
				fee schedules, and provider bulletins and updates specify covered and
				noncovered services and supplies.
(2) For additional information on existing
				medical coverage decisions or if you have a question about a new and emerging
				technology, device, or off-label use of a drug, contact the office of the
				medical director at:
Department of Labor and Industries
Office of the Medical Director
P.O. Box 44321
Olympia, WA 98504-4321
(3) For questions about what will be
				authorized on a specific claim, contact the self-insured employer or state fund
				claim manager.
Statutory Authority:
					 RCW
					 51.04.020 and
					 51.04.030. 00-01-037, §
					 296-20-02703, filed 12/7/99, effective
					 1/8/00.