Washington Administrative Code

The department will consider all of the information received from the training provider in its application for a provider number, including documents provided pursuant to WAC 296-19A-560. The department will review this information to ensure that the training provider provides se…

(1) A nonaccredited or unlicensed training provider without a current department provider number must be approved by the department and receive a provider number in order to train Washington injured workers. (2) A nonaccredited or unlicensed training provider who already has a de…

(1) All accredited or licensed training providers with a department provider number must maintain their accreditation or licensure status.(2) All approved nonaccredited or unlicensed training providers with department provider numbers must conform to all requirements in chapter 2…

(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 e…

(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 …

(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 tra…

(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 a…

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 rest…

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 Exception: A worker may elect Option 1 when the Option 2 election has been rescinded as provided by RCW 51.32.096 (5)(b).[Statutory Authority: RCW 51.04.020, …

(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 …

(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…

(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 perc…

(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) Th…

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). WSR 10-07-054, § 296-1…

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). WSR 10-07-054, § 29…

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). WSR 10-07-054, § 296-19A-660, filed 3/12/10, effective 4/12/10.…

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). WSR 10-07-054, § 296-19A-670, filed 3/12/10, effective 4/12/10.]

(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 pers…

(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 …

(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 shal…

Acceptance, accepted condition: Determination by a qualified representative of the department or self-insurer that reimbursement for the diagnosis and curative or rehabilitative treatment of a worker's medical condition is the responsibility of the department or self-insurer. The…

(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 Janua…

(1) The department or its delegated entity will review the provider's application, supporting documents, and any other information requested or accessed by the department that is relevant to verifying the provider's application, clinical experience or ability to meet or maintain …

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 standa…

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) Maint…

(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 th…

(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 co…

(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, f…

(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;…

(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 depart…

(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 i…

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 …

(1) Physician assistants may be "attending providers" pursuant to WAC 296-20-01002, under the workers' compensation system. They may be approved for payment for those medical services for which the physician assistant is trained and licensed, under a collaboration agreement with …

The department will not pay for services performed by the following practitioners:HerbalistsChristian Science practitioners or theological healersHomeopathistsNoncertified physician assistantsOperating room techniciansCertified surgical techniciansCertified surgical assistantsAny…

The filing of the Report of Accident (Workplace Injury, Accident or Occupational Disease) form or the Provider's Initial Report form, where applicable; or the rendering of treatment to a worker who comes under the department's or self-insurer's jurisdiction, as the case may be, c…

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 service…

(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 bas…

(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 p…

(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 …

(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 …

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 pro…

(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) P…

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 cov…

The director or the director's designee makes medical coverage decisions.[Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-037, § 296-20-02701, filed 12/7/99, effective 1/8/00.]

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…

(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-la…

(1) In making medical coverage decisions, the director or the director's designee considers information from a variety of sources. These sources include, but are not limited to:• Scientific evidence; • National and community-based opinions;• Informal syntheses of provider opinion…

(1) Treatment and diagnostic guidelines are developed by the department for the diagnosis or treatment of accepted conditions. These guidelines are developed to give providers a range of the many treatment or diagnostic options available for a particular medical condition. Treatm…

(1) The department or self-insurer will not authorize nor pay for treatment measures of a controversial, obsolete, investigational or experimental nature. (See WAC 296-20-03002.) Under certain conditions, the director or the director's designee may determine that such treatment i…

(1) A maximum of 20 office calls for the treatment of the industrial condition, during the first 60 days, following injury. Subsequent office calls must be authorized. Reports of treatment rendered must be filed at 60-day intervals to include number of office visits to date. See …