reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-257 - When a self-insured employer is subject to corrective action or withdrawal of certification as instituted by the director

Current through Register Vol. 24-14, July 15, 2024
(1) This section applies to withdrawal of
			 certification or corrective action instituted by the director pursuant to
			 RCW
			  51.14.080 and/or 51.14.095.
(2) The director or the director's designee
			 shall take corrective action against a self-insured employer if the director
			 determines that:
(a) The self-insured
			 employer is not following proper industrial insurance claims
			 procedures;
(b) The self-insured
			 employer's accident prevention program is inadequate;
(c) The employer no longer meets the
			 requirements of a self-insurer;
(d)
			 The self-insurer's deposit is insufficient;
(e) The self-insurer intentionally or
			 repeatedly induces employees to fail to report injuries, induces workers to
			 treat injuries in the course of employment as off-the-job injuries, persuades
			 workers to accept less than the compensation due, or unreasonably makes it
			 necessary for workers to resort to proceedings against the employer to obtain
			 compensation;
(f) The self-insurer
			 habitually fails to comply with rules and regulations of the director regarding
			 reports or other requirements necessary to carry out the purposes of this
			 title;
(g) The self-insurer
			 habitually engages in a practice of arbitrarily or unreasonably refusing
			 employment to applicants for employment or discharging employees because of
			 nondisabling bodily conditions;
(h)
			 The self-insurer fails to pay an insolvency assessment under the procedures
			 established pursuant to
			 RCW
			  51.14.077; or
(i) A self-insured employer violated the duty
			 of good faith and fair dealing two times within a three-year period.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-260 - Corrective action or withdrawal of certification

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Corrective action against a self-insured employer shall be by order and notice.
			 A notice of corrective action shall include the nature and specifics of the
			 findings and may include the following:
(a)
			 Probationary certification status for the self-insured employer for a period
			 not to exceed one year;
(b)
			 Mandatory training to correct areas of program deficiency to be approved by the
			 department.
The subject matter to be covered shall be specified in the
				notice of corrective action. Personnel required to attend and the time period
				within which the training is to be conducted will also be identified.
(c) Monitoring activities of the
			 self-insured employer for a specified period of time to determine progress
			 regarding correction of program deficiencies may be required. The department
			 may require submission of complete and accurate records and/or conduct an audit
			 to verify program compliance.
(d)
			 If there is a contract between the self-insured employer and a service
			 organization which has been filed with the department (WAC 296-15-110), the
			 corrective action order may specify and require that the service organization
			 be subject to mandatory training and monitoring of activity provisions of the
			 order.
(e) The corrective action
			 order shall specify a time frame for submission of progress reports to the
			 department's self-insurance section.
(f) During the first 30 days following the
			 corrective action order, the self-insured employer shall submit a plan for the
			 implementation of corrective action which shall include specific completion
			 dates. If the plan is determined to be incomplete or inadequate, the
			 department's self-insurance administrator shall notify the self-insurer of the
			 necessary requirements or changes needed, and shall specify the date by which
			 an amended plan shall be submitted.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-266 - Penalties

Current through Register Vol. 24-14, July 15, 2024
(1)
Under
			 what circumstances will the department consider assessing a penalty for an
			 unreasonable delay of benefits?
Upon a worker's or beneficiary's request
			 or based upon its own motion, the department will consider assessment of an
			 unreasonable delay of benefits penalty for:
(a) Time-loss compensation benefits if:
(i) The self-insurer has written medical
			 certification based on objective findings from the attending provider
			 authorized to treat that the worker is unable to work because of conditions
			 proximately caused by the industrial injury or occupational disease;
(ii) The worker is participating in a
			 department-approved vocational plan;
(iii) The self-insurer fails to make the
			 first time-loss payment to the worker within 14 calendar days of notice that
			 there is a claim;
(iv) The
			 self-insurer fails to continue time-loss payments on regular intervals as
			 required by
			 RCW
			  51.32.190(3); or
(v) The self-insurer fails to take action per
			 WAC 296-15-425.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-268 - Self-insurance penalty calculations

Current through Register Vol. 24-14, July 15, 2024
(1) For
			 all penalties assessed per WAC
			 296-15-266,
			 RCW
			  51.48.017,
			 51.48.080, or
			 51.14.180, the penalty amount
			 shall be determined by weighing the following factors:
(a) Amount of delayed payment.
(b) Length of time of the delay.
(c) History or past practice.
(d) Whether the department has issued an
			 order directing the payment.
(e)
			 Required adjustments to the amount of the payment.
(f) Number of unaddressed requests for action
			 to be taken by the employer or third-party administrator made by the
			 department, worker/beneficiary, or provider.
(g) Efforts by the employer or third-party
			 administrator to communicate with the worker, including communication of the
			 basis for or calculation of a payment.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-270 - Violation of the duty of good faith and fair dealing

Current through Register Vol. 24-14, July 15, 2024
(1) If a self-insured employer (SIE) or
			 third-party administrator (TPA) subject to the good faith and fair dealing duty
			 manages the workers' compensation claim in a manner which demonstrates a
			 greater concern for the self-insured employer's interest than the worker's
			 interest, the SIE/TPA will be in violation of its duty to engage in good faith
			 and fair dealing. Additionally, violation of the SIE/TPA duty to engage in good
			 faith and fair dealing includes repeatedly engaging in any of the following
			 actions with such frequency as to indicate a general business practice:
(a) When requesting an interlocutory order
			 pursuant to WAC
			 296-15-420(2):
			 Fails to provide a reasonable explanation for an interlocutory order, fails to
			 exercise due diligence while investigating claim determination, and/or fails to
			 provide provisional benefits as entitled during the interlocutory
			 period.
(b) Unreasonably delays or
			 refuses to pay wage replacement benefits without a factual, legal, vocational,
			 or medical basis.
(c) Fails to
			 ensure appropriate handling of claims pursuant to WAC
			 296-15-350.
(d) Fails to request claim denial or
			 interlocutory order pursuant to WAC
			 296-15-420 within 60
			 days.
(e) Fails to authorize
			 medical care pursuant to WAC
			 296-15-330 or without factual,
			 legal, or medical basis.
(f) Fails
			 to pay compensation pursuant to WAC
			 296-15-340.
(g) Fails to adhere to duties and performance
			 requirements pursuant to WAC
			 296-15-550.
(h) Fails to provide a copy of the claim file
			 in a timely manner pursuant to
			 RCW
			  51.14.120.
(i) Fails to communicate with injured workers
			 using department-developed templates pursuant to WAC
			 296-15-425, including use of the
			 templates in the workers preferred language.
(j) Fails to notify the worker or beneficiary
			 of their rights and obligations pursuant to WAC
			 296-15-400,
			 RCW
			  51.28.010 or
			 51.28.030.
(k) Requests the department issue an order
			 denying the claim without a factual, legal, or medical basis.
(l) Fails to provide a worker or beneficiary
			 a SIF-2 or ability to file a claim pursuant to WAC
			 296-15-320 and
			 296-15-405.
(m) Fails to have claims managed by a
			 certified claims administrator or trainee in accordance with WAC
			 296-15-350(2).
(n) Fails to forward an application to reopen
			 a claim within five working days of receipt pursuant to WAC
			 296-15-470.
(o) Fails to forward a protest or appeal to
			 the department within five working days of receipt pursuant to
			 RCW
			  51.14.120(2) and WAC
			 296-15-480.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-272 - When intentional behavior is deemed a violation of the duty of good faith and fair dealing

Current through Register Vol. 24-14, July 15, 2024
(1) If a
			 self-insured employer (SIE) or third-party administrator (TPA) subject to the
			 duty of good faith and fair dealing intentionally engages in any of the
			 following actions, the SIE/TPA is in violation of its duty to engage in good
			 faith and fair dealing if it fails to:
(a)
			 Provide a worker or beneficiary a SIF-2 or ability to file a claim pursuant to
			 WAC 296-15-320 and
			 296-15-405, with the intent to
			 interfere with the worker's ability to pursue benefits under Title 51
			 RCW.
(b) Forward an application to
			 reopen a claim within five working days of receipt pursuant to WAC
			 296-15-470, with the intent to
			 interfere with the worker's ability to reopen a claim or pursuing further
			 benefits.
(c) Forward a protest or
			 appeal to the department within five working days of receipt pursuant to
			 RCW
			  51.14.120(2) and WAC
			 296-15-480, with the intent to
			 interfere with the worker's ability to pursue a request for reconsideration,
			 appeal, or further benefits.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-310 - Administrative organization to manage a self-insurance program

Current through Register Vol. 24-14, July 15, 2024
Every employer certified to self-insure is obligated to comply
				with the provisions of
				Title
				51 RCW and the rules and
				regulations of the department, and to have the necessary administrative
				processes in place to manage its self-insurance program. Each self-insurer is
				ultimately responsible for the sure and certain delivery of
				Title
				51 RCW benefits to its injured
				workers and is accountable for all aspects of its workers' compensation
				program.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-310, filed 2/28/06, effective
				  4/1/06.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-320 - Reporting of injuries What elements must a self-insurer have in place to ensure the reporting of injuries?

Current through Register Vol. 24-14, July 15, 2024
Every self-insurer must:
(1)
			  Establish procedures to assist injured workers in reporting and
			 filing claims.
(a)  Immediately provide a
			 Self-Insurer Accident Report (SIF-2) form F207-002-000 to every worker who
			 makes a request, or upon the self-insurer's first knowledge of the existence of
			 an industrial injury or occupational disease, whichever occurs first.
(b)  Establish procedures for ensuring the
			 timely delivery of completed SIF-2s to the claims management entity.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-330 - Authorization of medical care

Current through Register Vol. 24-14, July 15, 2024
What are the requirements for authorization of medical
				care?
Every self-insurer must:
(1)
			  Authorize treatment and pay bills in accordance with Title 51 RCW
			 and the medical aid rules and fee schedules of the state of
			 Washington.
(2)  Provide a written
			 explanation of benefits (EOB) to the provider, with a copy to the worker if
			 requested, for each bill adjustment. A written explanation is not required if
			 the adjustment was made solely to conform to the maximum allowable fees as set
			 by the department.
(3)  Provide a
			 written explanation to the worker and provider(s) regarding any denied bill.
			 Bills returned to the provider because a proper bill was not submitted under
			 WAC
			 296-20-125 do
			 not require a written explanation.
(4)
			  Establish procedures to ensure prompt responses to inquiries
			 regarding authorization decisions and bill adjustments.
(5)  Comply with the requirements of the
			 health care provider network. This includes:
(a)
			  Utilizing only those providers approved for the provider network,
			 except when the provider specialty or geographic location is not yet covered by
			 the network;
(b)  Providing
			 information to workers about the requirement for providers to be enrolled in
			 the network in order to treat injured workers and information on how a worker
			 can find network providers. This information must be included in publications
			 used by self-insurers to comply with WAC
			 296-15-400(2)(a);
(c)  Ensuring, when applicable, that only
			 network providers are paid for care after the initial office or emergency room
			 visit; and
(d)  Promptly assisting
			 workers who are being treated by a nonnetwork provider to transfer their care
			 to a network provider of their choice; including, at a minimum, notification to
			 the worker within forty-five days of receipt of the first bill from a
			 nonnetwork provider that the provider will not be paid for treatment beyond the
			 initial visit on the claim and information about how to find network
			 providers.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-340 - Payment of compensation

Current through Register Vol. 24-14, July 15, 2024
What are the requirements for payment of
				compensation?
Every self-insurer must:
(1)
			  Pay time-loss compensation in accordance with Title 51 RCW and
			 the rules and regulations of the department.
(2)
			  Provide to workers a statement of benefits with each time-loss
			 payment, to include the type of benefit paid and the period paid with from and
			 to dates. If authorized by the worker, an electronic statement may be provided.
			 In addition, provide to workers a statement of benefits with payments for
			 reimbursements to workers.
(3) 
			 When payable, time-loss must continue at regular semi-monthly or bi-weekly
			 intervals. When making an initial payment, an employer may adjust the date for
			 payment of time-loss to align with a worker's normal date for payment of wages;
			 however, the payment must be made within ten days of the entitlement
			 period.
Statutory Authority:
				  RCW
				   51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-340, filed 2/28/06, effective
				  4/1/06.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-350 - Handling of claims

Current through Register Vol. 24-14, July 15, 2024
What elements must a self-insurer or third-party
				administrator (TPA) have in place to ensure appropriate handling of
				claims?
Every self-insurer or TPA must:
(1) Establish procedures for securing the
			 confidentiality of claim information.
(2) Have sufficient numbers of certified
			 claims administrators to ensure uninterrupted administration of claims. In this
			 regard:
(a) Effective July 1, 2021, every
			 person making claim decisions must be a certified claims administrator or in
			 the process of getting their certification. For the purposes of this section,
			 every person making claim decisions includes:
(i) Those persons who manage claims directly;
			 and
(ii) Who request to allow or
			 deny claims under WAC
			 296-15-420;
(iii) Take action on claims under WAC
			 296-15-425;
			 or
(iv) Close claims under WAC
			 296-15-450.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-360 - Qualifications of personnel-Certified claims administrators

Current through Register Vol. 24-14, July 15, 2024
(1)
What is a certified claims
			 administrator?
An experienced adjudicator who has been certified by the
			 department to meet the requirements of WAC
			 296-15-350(2).
(2)
How do I become a certified claims
			 administrator for self-insured claims?
(a) Under the mentorship of a certified
			 claims administrator, have a minimum of one year of experience in the
			 administration or oversight of claims under Title 51 RCW. The experience must
			 have occurred within the five years immediately prior to your filing of the
			 application to take the "selfinsurance claims administrator" test.
(b) Have completed:
(i) A comprehensive goal-oriented curriculum
			 approved by the department and resulting in a worker's compensation
			 professional designation; or
(ii)
			 An approved training program within the department.
(c) Take and pass the department's
			 "self-insurance claims administrator" test. The department will provide annual
			 reports to stakeholders. The department will report the results, identify and
			 consider feasible alternative methods of test delivery, make any
			 recommendations for improvements if appropriate and seek comments from
			 stakeholders.
(i) If you have the requisite
			 experience under (a) of this subsection, you may take the test without
			 completing the training required under (b)(i) or (ii) of this subsection. The
			 provision to take the test for certification without completing the requisite
			 training will expire January 1, 2022.
(ii) If you have already passed the test and
			 are a certified claims administrator, you will maintain your certified claims
			 administrator designation without completing the training required under (b)(i)
			 or (ii) of this subsection, and you will need to fulfill the continuing
			 education credits under subsection (6) of this section.
After passing the test, you are designated a certified claims
				administrator. This is a lifetime certification, provided that continuing
				education requirements are met.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-370 - Notification to the department

Current through Register Vol. 24-14, July 15, 2024
When must a self-insurer notify the department about
				changes in its administrative organization?
Any changes to the
				self-insurer's established administrative organization must be reported to the
				department in writing, within ten days of the effective date of the
				change.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-370, filed 2/28/06, effective
				  4/1/06.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-400 - Self-insured workers' rights and obligations How must a self-insurer notify its workers of their rights and obligations under the industrial insurance laws?

Current through Register Vol. 24-14, July 15, 2024
Self-insurers must notify workers of their industrial insurance
				rights and obligations at the following times:
(1)
			  Within thirty days of hire, provide a form substantially similar
			 to the one page Workers' Compensation Filing Information L&I form
			 F207-155-000, or if authorized by the worker provide a link to the form giving
			 electronic access online in lieu of a paper form.
(2)  When a worker files a claim, provide the
			 following information in writing:
(a)  The
			 current edition of the department's pamphlet P207-085-000,
A Guide to
			 Workers' Compensation Benefits for Employees of Self-Insured
			 Businesses
, or if authorized by the worker provide a link to the
			 pamphlet giving electronic access online in lieu of a paper pamphlet;
			 and
(b)  The name, address, and
			 phone number of the person or organization handling the worker's
			 claim.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-405 - Filing a self-insured claim

Current through Register Vol. 24-14, July 15, 2024
(1)
What form is used to report a self-insured worker's industrial injury or
			 occupational illness?
The reporting form for a self-insured worker's industrial
				injury or occupational illness is the Self-Insurer Accident Report (SIF-2)
				L&I form F207-002-000. Self-insurers must obtain these forms from the
				department and must report their workers' industrial injuries and illnesses to
				the department with SIF-2s. The department tracks the claim numbers assigned to
				self-insurers.
When notified of injury or illness, the self-insurer must
				provide the worker with this prenumbered form and assistance in filing a claim.
				The self-insurer must provide the worker the designated copy of the completed
				SIF-2 (which includes an explanation of the worker's rights and
				responsibilities) within five working days of completion.
(2)
What form does a health care
			 provider use to report a self-insured worker's industrial accident or
			 occupational illness?
Physicians should report a self-insured claim with a Provider's
				Initial Report (PIR) L&I form F207-028-000 when a self-insured worker has
				an industrial injury or is notified of an occupational illness. Replacements
				are acceptable.
Statutory Authority:
				  RCW
				   51.32.190(6),
				  51.32.055(8)(a) and
				  (9)(a). 98-24-121, § 296-15-405, filed
				  12/2/98, effective 1/2/99.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-420 - Requesting allowance or denial, or interlocutory order from the department-Providing claim file

Current through Register Vol. 24-14, July 15, 2024
(1)
How must
			 a self-insurer request claim allowance on a time-loss compensation
			 claim?
Within sixty days of notice of claim, a self-insurer must:
(a)  Send a department-developed
			 form1 requesting allowance to the department (may be
			 submitted electronically or paper copy), and attach copies of the SIF-2 and
			 SIF-5A2. The department will allow the claim unless
			 a request for interlocutory order (see subsection (2) of this section) or
			 denial (see subsection (3) of this section) has been received.
(b)  If the injured worker is kept on salary,
			 send copies of the department-developed form3 and
			 SIF-5A within five working days of the date the first time-loss payment would
			 have been due. The department will allow the claim UNLESS a request for
			 interlocutory order (see subsection (2) of this section) or denial (see
			 subsection (3) of this section) has been received.
1
The department-developed form is the form used to
						  request allowance (formerly SIF-5).
2
The SIF-5A is the time-loss calculation rate notice.
						  Use a form substantially similar to L&I form F207-156-000.
3
If the worker is kept on salary, report the amount of
						  time-loss the worker would have been entitled to on the department-developed
						  form.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-425 - Communicating to injured workers during the course of the claim

Current through Register Vol. 24-14, July 15, 2024
(1)  How does a
			 self-insurer communicate claims administration actions to workers?
The self-insurer must communicate in writing using a
				department-developed template to inform workers of actions involving delivery
				of benefits.
(2)
What
			 is the purpose of the department-developed template?
To provide timely and accurate delivery of benefits and prompt
				resolution of disputes during the course of a claim (between the allowance and
				closure of a claim); to promote efficient claims processing that is protective
				of workers and effective for employers by improving communications to workers,
				clarifying requirements and providing certainty of claims administration for
				self-insurers, and streamlining regulatory oversight by the department.
(3)
When must a
			 department-developed template be completed and sent to the worker?
Within five days of a claims administrator taking action on a
				claim involving:
(a)  Calculation of
			 the worker's monthly wage that forms the basis for time-loss compensation at
			 time of payment;1
(b)
			  Starting*, stopping, or denying time-loss or loss of earning
			 power compensation;
(c)  Acceptance
			 or denial of a condition contended under the claim;
(d)  Authorization or denial of treatment
			 requested by a medical provider with specified diagnosis and procedure codes
			 for treatment requiring authorization under WAC
			 296-20-03001;
			 or
(e)  Assessment of an
			 underpayment or overpayment of benefits (from date of knowledge).
*
When starting time-loss compensation the self-insurer
						  must send a copy of the department-developed template and SIF-2 to the
						  department.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4302 - What is the Self-Insurance Vocational Reporting Form?

Current through Register Vol. 24-14, July 15, 2024
The Self-Insurance Vocational Reporting Form replaces the
				Employability Assessment Report (EAR) and is used as a cover sheet for all
				vocational reports submitted to the department by the self-insured
				employer.
Note:
A Self-Insurance Vocational Reporting Form is not
							 required if the worker is not eligible for vocational services because they
							 returned or were released to work at the job at the time of injury or on the
							 date of disease manifestation.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4302, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4304 - What must the self-insurer do when an assessment report is received?

Current through Register Vol. 24-14, July 15, 2024
(1) A self-insurer
			 must submit a Self-Insurance Vocational Reporting Form and the assessment
			 report to the department within ten working days after receiving the completed
			 report. A completed report is one that, in the opinion of the department, meets
			 the requirements in WAC
			 296-19A-070.
(2) When time-loss is terminated, based on
			 the vocational rehabilitation provider's recommendations, the self-insurer must
			 notify the worker or the worker's representative as required in WAC
			 296-15-420(9).
(3) The self-insurer can terminate time-loss
			 on the date they receive the recommendation but, if the department determines
			 the assessment report failed to demonstrate the worker is able to work, the
			 self-insurer must request additional information from the vocational
			 rehabilitation provider before resubmitting the report and an updated
			 Vocational Services Reporting Form to the department.
(4) If the self-insurer terminated time-loss
			 based on the assessment report's recommendation but the department concludes
			 the assessment report failed to demonstrate the worker is able to work, the
			 self-insurer must reinstate time-loss effective the day after the last date
			 paid.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4304, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4306 - When must a self-insurer submit a vocational rehabilitation plan to the department?

Current through Register Vol. 24-14, July 15, 2024
No later than ninety calendar days after the date the
				department determined the worker was eligible for vocational plan development
				services, the employer must submit a Self-Insurance Vocational Reporting Form
				and a completed vocational plan for the worker.
If the plan cannot be completed and submitted to the department
				within that time period, the self-insurer must, prior to the ninetieth day,
				submit a Self-Insurance Vocational Reporting Form and the vocational
				rehabilitation provider's request for an extension as required in WAC
				296-19A-094.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4306, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4308 - What must the vocational rehabilitation plan include?

Current through Register Vol. 24-14, July 15, 2024
The vocational rehabilitation plan must meet the requirements
				in WAC 296-19A-100.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4308, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4310 - What must the self-insurer do when the department denies the vocational rehabilitation plan?

Current through Register Vol. 24-14, July 15, 2024
The vocational rehabilitation plan may be denied if the plan
				does not meet the requirements in WAC
				296-19A-100 and the department
				cannot make a determination based on the information provided.
If the plan does not meet the requirements or is denied as
				incomplete, the self-insurer must correct the plan and/or obtain the
				information requested by the department, and resubmit the completed plan and an
				updated Vocational Services Reporting Form.
If the plan cannot be corrected and/or completed and submitted
				to the department within ninety calendar days after the date the department
				determined the worker was eligible for vocational plan development services,
				the self-insurer must, prior to the ninetieth day, submit a Self-Insurance
				Vocational Reporting Form and the vocational rehabilitation provider's request
				for an extension as required in WAC
				296-19A-094.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4310, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4312 - What must the self-insurer do when the vocational rehabilitation plan is successfully completed?

Current through Register Vol. 24-14, July 15, 2024
The self-insurer must:
(1) Notify the worker or the worker's
			 representative of the time-loss termination as required in WAC
			 296-15-420(9).
(2) Submit a Self-Insurance Vocational
			 Reporting Form to the department within ten working days of the date time-loss
			 benefits ended. The Self-Insurance Vocational Reporting Form must include:
(a) The total cost and time expended for the
			 approved plan;
(b) The total
			 time-loss compensation benefits paid during the plan implementation;
			 and
(c) The total vocational
			 services costs and time-loss days paid since the date the worker was found
			 eligible for services; and
(d) A
			 closing report with a copy to the worker or the worker's representative. The
			 closing report must meet the requirements in WAC
			 296-19A-120.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4314 - What must the self-insurer do if the vocational rehabilitation plan is not successfully completed?

Current through Register Vol. 24-14, July 15, 2024
When a vocational rehabilitation plan ends before successful
				completion, the vocational rehabilitation provider will submit a closing report
				to the self-insurer.
(1)
Plan
			 not completed due to causes outside the worker's control.
Within ten
			 working days of receiving the vocational closing report, the self-insurer must:
(a) Continue time-loss benefits;
			 and
(b) Submit a Self-Insurance
			 Vocational Reporting Form to the department. The form must include:
(i) The total cost and time expended for the
			 approved plan;
(ii) The total
			 time-loss compensation benefits paid during the plan implementation;
(iii) The total vocational services costs and
			 time-loss days paid since the date the worker was found eligible for services;
			 and
(iv) A closing report with a
			 copy to the worker or the worker's representative. The closing report must meet
			 the requirements in WAC
			 296-19A-120(2).
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4316 - What must the self-insurer do when the worker declines further vocational rehabilitation services and elects option 2 benefits?

Current through Register Vol. 24-14, July 15, 2024
When the department approves a rehabilitation plan, the
				department will notify the worker in writing of their right to decline further
				vocational rehabilitation services and elect option 2 benefits. The worker must
				make an election within the time frame required in WAC
				296-19A-600.
				When the worker elects option 2 benefits, the self-insurer must take the
				following action within five working days of receiving the worker's
				request:
(1)  Submit a Self-Insurance
			 Vocational Reporting Form to the department. The Self-Insurance Vocational
			 Reporting Form must include:
(a)  The total
			 vocational services costs paid since the date the worker was found eligible for
			 services; and
(b)  The option 2
			 election form signed by the worker.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-4318 - What must the self-insurer do when the worker elects option 2 benefits and the claim is closed?

Current through Register Vol. 24-14, July 15, 2024
The self-insurer must submit a quarterly report to the
				department on a form stipulated by the department listing the total retraining
				costs paid to date for each worker since the option 2 benefit was granted.
				These quarterly reports must document all funds expended and funds that remain
				available for all workers of the employer until each worker has expended the
				total vocational costs available to him or her, or until five years have passed
				since the benefit was granted.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.04.030,
				  51.32.095,
				  51.32.099 and
				  51.32.0991 (2007 c 72). 08-06-058,
				  § 296-15-4318, filed 2/29/08, effective
				  3/31/08.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-440 - Use of independent medical examinations What will the department consider when resolving a dispute to a scheduled independent medical exam (IME) in a self-insured claim?

Current through Register Vol. 24-14, July 15, 2024
(1)
The department will consider whether:
(a) The notification letter included the
			 self-insured employer's need for the IME consistent with
			 RCW
			  51.36.070 and how this may be disputed by the
			 worker.
(b) Notice of the IME was
			 mailed to the injured worker and the worker's representative no later than 28
			 calendar days prior to the IME. Except for an IME scheduled to make a decision
			 regarding claim allowance.
(c) The
			 worker agreed to waive the 28 day notice for initial IME scheduling or
			 reschedules.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-450 - Closure of self-insured claims

Current through Register Vol. 24-14, July 15, 2024
(1)
Who closes self-insured claims?
The department has the authority to close all self-insured
				claims. Self-insurers have the authority to close certain claims.
Within two years of claim closure on a claim the self-insurer
				closed, the department may require a self-insurer to pay additional benefits if
				the self-insurer:
(a)  Made a clerical
			 error in benefits paid;
(b)  Paid
			 benefits due to mistake of identity or innocent misrepresentation; or
(c)  Violated the conditions of claim
			 closure.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-470 - When a worker files for reopening

Current through Register Vol. 24-14, July 15, 2024
When must a self-insurer forward an application to reopen
				a claim to the department?
A self-insurer must forward an application to
				reopen a claim to the department within five working days of
				receipt.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-470, filed 2/28/06, effective
				  4/1/06.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-480 - When a self-insured claim is protested

Current through Register Vol. 24-14, July 15, 2024
When must a self-insurer submit a worker's written
				protest or appeal to the department?
A self-insurer must submit a written protest by a worker to the
				department within five working days of receipt. The date the protest is
				received by the self-insurer is considered the date the protest is received by
				the department.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-480, filed 2/28/06, effective 4/1/06. Statutory Authority:
				  RCW
				   51.32.190(6),
				  51.32.055(8)(a) and
				  (9)(a). 98-24-121, § 296-15-480, filed
				  12/2/98, effective 1/2/99.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-490 - When a self-insured claim is on appeal

Current through Register Vol. 24-14, July 15, 2024
(1)
When must a self-insurer submit a
			 worker's written appeal to the department?
A self-insurer must submit to
			 the department a written appeal by a worker within five working days of
			 receipt. The date the appeal is received by the self-insurer is considered the
			 date the appeal is received by the department.
(2)
How may department orders be
			 defended in self-insured appeals?
The department may ask the office of the attorney general to
				represent the department at the board of industrial insurance appeals.
(3)
What must a self-insurer
			 send to the department when any party appeals a claim to superior or appellate
			 court?
When any party appeals a claim to superior or appellate court,
				the self-insurer must promptly send to the department copies of the notice of
				appeal, judgment, and all other relevant information.
Statutory Authority:
				  RCW
				  51.04.020,
				  51.14.020,
				  51.32.190,
				  51.14.090, and
				  51.14.095. 06-06-066, §
				  296-15-490, filed 2/28/06, effective 4/1/06. Statutory Authority:
				  RCW
				   51.32.190(6),
				  51.32.055(8)(a) and
				  (9)(a). 98-24-121, § 296-15-490, filed
				  12/2/98, effective 1/2/99.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-495 - Third party action on a self-insured claim

Current through Register Vol. 24-14, July 15, 2024
What must a self-insurer send to the department when
				there is a third-party action?
When there is a third-party action, in addition to fulfilling
				the statutory requirements, the self-insurer must send the department copies
				of:
When
What
Upon notification
Written indication of the worker's election.
After recovery of damages
1. Signed settlement agreement or court order;
							 and
2. Total amount of attorney fees and costs;
							 and
3. Total amount of benefits paid, including TL, PPD,
							 and medical, excluding payments for IMEs.
Statutory Authority:
				  RCW
				  51.32.190(6),
				  51.32.055(8)(a) and
				  (9)(a). 98-24-121, § 296-15-495, filed
				  12/2/98, effective 1/2/99.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-520 - Self-insured third-party administrator (TPA) licensing requirements

Current through Register Vol. 24-14, July 15, 2024
To be licensed as a TPA, a business entity must:
(1) Be licensed to do business in the state
			 of Washington, as evidenced by holding a business license from the department
			 of revenue;
(2) Demonstrate to the
			 department's satisfaction that it can meet the requirements for handling claims
			 under WAC
			 296-15-350 for
			 the self-insured employers it contracts with; and
(3) Comply with the reporting requirements of
			 these rules in accordance with Title 51 RCW.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-530 - Self-insured third-party administrator (TPA) licensing application requirements

Current through Register Vol. 24-14, July 15, 2024
(1) To apply
			 for a TPA license, a business entity must:
(a) Submit to the department a
			 department-developed application;
(b) Provide a list of the self-insured
			 employers in Washington the TPA is under contract to handle claims
			 for;
(c) Provide a list of their
			 certified claims administrators; and
(d) Provide a list of their claims
			 administrators in the process of obtaining their certification in accordance
			 with WAC
			 296-15-360.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-540 - Self-insured third-party administrator (TPA) licensing renewal application requirements

Current through Register Vol. 24-14, July 15, 2024
(1) A TPA must
			 apply annually to renew its license. To apply, the TPA must:
(a) Submit a department-developed renewal
			 application to the department;
(b)
			 Provide an updated list of the self-insured employers in the state of
			 Washington the TPA handles claims for;
(c) Provide an updated list of their
			 certified claims administrators; and
(d) Provide an updated list of their claims
			 administrators in the process of obtaining their certification in accordance
			 with WAC
			 296-15-360.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-550 - Self-insured third-party administrator (TPA) duties and performance requirements

Current through Register Vol. 24-14, July 15, 2024
Every TPA must:
(1)
			 Agree to be responsible for ensuring that claims are managed in accordance with
			 Title 51 RCW, Washington Administrative Codes, L&I policies, L&I
			 medical treatment guidelines, and medical aid fee schedule.
(2) Follow recognized claim processing
			 practices to include:
(a) Promptly respond to
			 inquiries from workers, L&I, ombuds office, and medical providers:
(i) Telephone inquiries within three business
			 days; and
(ii) Written
			 correspondence within fifteen business days, unless otherwise
			 specified.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-560 - Self-insured third-party administrator (TPA) penalties

Current through Register Vol. 24-14, July 15, 2024
(1) A TPA may be
			 penalized under
			 RCW
			  51.48.080 for deficiencies involving, but not
			 limited to:
(a) Failure to maintain the
			 requirements under WAC
			 296-15-425,
			 296-15-520,
			 or
			 296-15-550.
			 Beginning July 1, 2023, as authorized by
			 RCW
			  51.48.095, this penalty will be adjusted for
			 inflation every three years based on the consumer price index (Seattle,
			 Washington area for urban wage earners and clerical workers, all items compiled
			 by the Bureau of Labor Statistics of the United States Department of Labor) and
			 posted to the L&I website.
(b)
			 The department will not assess additional penalties under
			 RCW
			  51.48.017 when a TPA:
(i) Promptly self-assesses;
(ii) Correctly calculates the amount of the
			 penalty;
(iii) Reports to the
			 department; and
(iv) Pays to the
			 worker a penalty not to exceed the greater of $1,000 or 25 percent upon
			 discovery of the delayed payment, unless the department determines there is a
			 reoccurring issue or establishes additional benefits have been
			 delayed.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-15 - Workers' compensation self-insurance rules and regulations › Section 296-15-570 - Self-insured third-party administrator (TPA) license suspension and revocation

Current through Register Vol. 24-14, July 15, 2024
A TPA's license may become provisional, suspended, or revoked
				if:
(1) Demonstrates a continuing
			 practice of failure to maintain requirements or correct deficiencies. The
			 department may consider issuing a directive listing the specific areas of
			 noncompliance and requiring correction within time frames established by the
			 department; and
(2) If the
			 corrections are not made timely, then the department may issue an order of
			 suspension or revocation in accordance with
			 RCW
			  51.52.050.