Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › OPIOIDS FOR NONCANCER PAIN › Section 296-20-06101 - What reports are health care providers required to submit to the insurer?

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer requires different kinds of
				  information at various stages of a claim in order to approve treatment, time
				  loss compensation, and treatment bills. The information provided in these
				  reports is needed to adequately manage industrial insurance claims.
Report
Due/Needed by
							 Insurer
What Information Should Be Included In
							 the Report?
Special Notes
Report of Industrial Injury or Occupational
							 Disease
(form)
Immediately - Within five days of first visit.
See form
Only MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may
							 sign and be paid for completion of this form.
Self-Insurance: Provider's Initial
							 Report
(form)
If additional space is needed, please attach the
							 information to the application. The claim number should be at the top of the
							 page.
Sixty Day
(narrative)
Purpose:
Support and document the need
							 for continued care when conservative (non-surgical) treatment is to continue
							 beyond sixty days
Every sixty days when only conservative (nonsurgical)
							 care has been provided.
(1) The
conditions diagnosed,
including
							 the current federally adopted ICD-CM codes and the subjective complaints and
							 objective findings.
Providers may submit legible comprehensive chart
							 notes in lieu of sixty day reports
PROVIDED
the chart notes
							 include all the information required as noted in the "What Information Should
							 Be Included?" column.
(2) The
relationship of diagnoses,
if
							 any, to the industrial injury or exposure.
However,
office notes are not acceptable
							 in lieu of requested narrative reports and providers may not bill for the
							 report if chart notes are submitted in place of the report.
(3) Outline of
proposed treatment
							 program,
its length, components and expected prognosis including an
estimate of when treatment should be concluded
and condition(s)
							 stable. An
estimated return to work date
and the
probability,
if any,
of permanent partial disability
resulting from the industrial condition.
(4)
Current medications,
including
							 dosage and amount prescribed. With repeated prescriptions, include the plan and
							 need for continuing medication.
Providers must
include
their
name,
							 address and date
on all chart notes submitted.
(5) If the worker has not returned to work,
indicate whether a vocational assessment will be necessary
to
							 evaluate the worker's ability to return to work and why.
(6) If the worker has not returned to work, a
doctor's estimate of physical capacities
should be
							 included.
(7)
Response to any specific questions
asked by the insurer or vocational counselor.
Opioid Authorization Requirement
Opioids in subacute phase -Six weeks from the date of
							 injury or surgery.
Opioids in chronic phase -Twelve weeks from the date
							 of injury or surgery.
Opioids for ongoing chronic therapy - Every ninety
							 days.
Please see WAC
							 296-20-03056 through
							 296-20-03059 for documentation
							 requirements for those workers receiving opioids.
Special Reports/Follow-up Reports
(narrative)
As soon as possible following request by the
							 department/ insurer.
Response to any specific questions
asked
							 by the insurer or vocational counselor.
"Special reports" are payable only when requested by
							 the insurer.
Consultation Examination Reports
(narrative)
At one hundred twenty days if only conservative
							 (nonsurgical) care has been provided.
(1) Detailed history.
If the injured/ill worker had been seen by the
							 consulting doctor within the past three years for the same condition, the
							 consultation will be considered a follow-up office visit, not
							 consultation.
Purpose:
Obtain an objective evaluation
							 of the need for ongoing conservative medical management of the worker.
(2)
Comparative history
between the
							 history provided by the attending or treating provider and injured
							 worker.
(3) Detailed physical examination.
The attending or treating provider may choose the
							 consultant.
(4)
Condition(s) diagnosed
including the
							 current federally adopted ICD-CM codes, subjective complaints and objective
							 findings.
A copy of the consultation report must be submitted
							 to both the attending or treating provider and the department/ insurer.
(5) Outline of
proposed treatment
							 program:
Its length, components, expected prognosis including when
							 treatment should be concluded and condition(s) stable.
(6)
Expected degree of recovery
from the
							 industrial condition.
(7)
Probability of returning to regular
							 work
or modified work and an
estimated
return to work
date.
(8)
Probability,
if any, of
permanent partial disability
resulting from the industrial
							 condition.
(9) A doctor's
estimate of physical
							 capacities
should be included if the worker has not returned to
							 work.
(10)
Reports
of necessary, reasonable
X ray
and
laboratory
studies to establish or confirm
							 diagnosis when indicated.
Attending Provider Review of IME Report
(form)
Purpose:
Obtain the attending provider's opinion about the
							 accuracy of the diagnoses and information provided based on the IME.
As soon as possible following request by the
							 department/ insurer.
Agreement or disagreement with IME findings. If you
							 disagree, provide objective/subjective findings to support your
							 opinion.
Payable only to the attending provider upon request
							 of the department/insurer. PAs can concur with treatment recommendations but
							 not PPD ratings.
Loss of Earning Power
(form)
Purpose:
Certify the loss of earning power is due to the
							 industrial injury/occupational disease.
As soon as possible after receipt of the form.
See form
Payable only to the attending or treating
							 provider.
Application to Reopen Claim Due to Worsening of
							 Condition
(form)
Purpose:
Document worsening of the
							 accepted condition and need to reopen claim for additional treatment.
Immediately following identification of worsening
							 after a claim has been closed for sixty days.
Crime Victims:
Following identification
							 of worsening after a claim has been closed for ninety days.
See form
Only MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may
							 sign and be paid for completion of this form.
What documentation is required for initial and follow
				  up visits?
Legible copies of office or progress notes are required for
				  the initial and all follow-up visits.
What documentation are ancillary providers required to
				  submit to the insurer?
Ancillary providers are required to submit the following
				  documentation to the department or self-insurer:
Provider
Chart Notes
Reports
Audiology
X
X
Biofeedback
X
X
Dietician
X
Drug & Alcohol Treatment
X
X
Free Standing Surgery
X
X
Free Standing Emergency Room
X
X
Head Injury Program
X
X
Home Health Care
X
Infusion Treatment, Professional Services
X
Hospitals
X
X
Laboratories
X
Licensed Massage Therapy
X
X
Medical Transportation
X
Nurse Case Managers
X
Nursing Home
X
X
Occupational Therapist
X
X
Optometrist
X
X
Pain Clinics
X
X
Panel Examinations
X
Physical Therapist
X
X
Prosthetist/Orthotist
X
X
Radiology
X
Skilled Nursing Facility
X
X
Speech Therapist
X
X
Statutory Authority:
					 RCW
					  51.04.020 and
					 51.04.030. 13-12-024, §
					 296-20-06101, filed 5/28/13, effective 7/1/13. Statutory Authority: 2007 c 263,
					 RCW
					  51.04.020 and
					 51.04.030. 08-04-095, §
					 296-20-06101, filed 2/5/08, effective 2/22/08. Statutory Authority: 2004 c 65
					 and 2004 c 163. 04-22-085, § 296-20-06101, filed 11/2/04, effective
					 12/15/04. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030 and
					 51.36.060. 00-01-190, §
					 296-20-06101, filed 12/22/99, effective 1/24/00. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030 and 1993 c 159.
					 93-16-072, § 296-20-06101, 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), § 296-20-06101, filed 2/28/86, effective 4/1/86. Statutory
					 Authority:
					 RCW
					  51.04.020(4),
					 51.04.030, and
					 51.16.120(3).
					 81-24-041 (Order 81-28), § 296-20-06101, filed 11/30/81, effective 1/1/82;
					 81-01-100 (Order 80-29), § 296-20-06101, filed 12/23/80, effective 3/1/81;
					 Order 74-39, § 296-20-06101, filed 11/22/74, effective
					 1/1/75.