Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-20 - Medical aid rules › Section 296-20-010 - General information

Current through Register Vol. 24-14, July 15, 2024
(1) The
			 following rules are promulgated pursuant to
			 RCW
			  51.04.020 and
			 51.04.030. The department or
			 self-insurer may purchase necessary physician and other provider services
			 according to the fee schedules. The fee schedules shall be established in
			 consultation with interested persons and updated at times determined by the
			 department in consultation with those interested persons. Prior to the
			 establishment or amendment of the fee schedules, the department will give at
			 least thirty calendar days notice by mail to interested persons who have made
			 timely request for advance notice of the establishment or amendment of the fee
			 schedules. To request advance notice of the establishment or amendment of the
			 fee schedules, interested persons must contact the department at the following
			 address:
Department of Labor and Industries
Health Services Analysis
Interested Person's Mailing List for the Fee Schedules
P.O. Box 44322
Olympia, WA 98504-4322
As an alternative, interested persons may subscribe to the LI
				medical provider news listserv. To subscribe, go to the department's web site
				at
www.lni.wa.gov
and click on the link
				"Provider billing payment." Look for the icon that says "Get E-mail Updates"
				and click on it.
The department or self-insurer will require the current version
				of the federal Health Care Common Procedure Coding System (HCPCS) Level I (or
				CPT) and II codes on January 1st, of each new year. CPT refers to the American
				Medical Association's Physicians' Current Procedural Terminology codes.
The adoption of these codes on an annual basis is designed to
				reduce the administrative burden on providers and lead to more accurate
				reporting of services. However, the inclusion of a service, product or supply
				within these new codes does not necessarily imply coverage, reimbursement or
				endorsement, by the department or self-insurer. The department will make
				coverage and reimbursement decisions for these new codes on an individual
				basis.
If there are any services, procedures or narrative text
				contained in the new HCPCS Level I and II codes that conflict with the medical
				aid rules or fee schedules, the department's rules and policies take
				precedence.
Copies of the HCPCS Level I and II codes are available for
				public inspection. These documents are available in each of the department's
				service locations.
Copies of the HCPCS Level II codes may be purchased
				from:
The Superintendent of Documents
United States Government Printing Office
Washington, DC 20402 202-783-3238
Copies of the Level I (or CPT) codes may be purchased
				from:
The American Medical Association
Chicago, Illinois 60601 800-621-8335
In addition to the sources listed above, both the Level I and
				II codes may be purchased from a variety of private sources.
(2) The fee schedules are intended to cover
			 all services for accepted industrial insurance claims. All fees listed are the
			 maximum fees allowable. Practitioners shall bill their usual and customary fee
			 for services.
If a usual and customary fee for any particular service is
			 lower to the general public than listed in the fee schedules, the practitioner
			 shall bill the department or self-insurer at the lower rate.
The
			 department or self-insurer will pay the lesser of the billed charge or the fee
			 schedules' maximum allowable.
(3)
			 The rules contained in the introductory section pertain to
all
practitioners regardless of specialty area or limitation of practice.
			 Additional rules pertaining to specialty areas will be found in the appropriate
			 section of the medical aid rules.
(4) The methodology for making conversion
			 factor cost of living adjustments is listed in WAC
			 296-20-132. The conversion
			 factors are listed in WAC
			 296-20-135.
(5) L&I or self-insurers will not pay for
			 a missed appointment unless the appointment is for an examination arranged by
			 the department or self-insurer.
(6)
			 Other than missed appointments for examinations arranged by the department or
			 self-insurer, a provider may bill an injured worker for a missed appointment
			 if:
(a) The provider has a missed appointment
			 policy that applies to all patients without regard as to which insurer or
			 entitlement program may be responsible for payment; and
(b) The provider routinely notifies all
			 patients of the missed appointment policy.
The implementation and enforcement of the policy is a matter
				between the provider and the injured worker. L&I is not responsible for the
				implementation and/or enforcement of the provider's policy.