Washington Administrative Code

Job analyses (JAs) sent to the IME provider at the time of the IME referral must be completed and submitted with the IME report. JAs submitted within sixty calendar days after the IME must be completed and returned within fourteen calendar days of receipt of the JAs.[Statutory Au…

No. However, if a worker voluntarily approaches an IME provider who has previously examined the worker and asks to be treated by that provider, the provider can treat the worker. The provider must document that the worker was aware of other treatment options.[Statutory Authority:…

When there is no approved examiner in the worker's community or in a reasonably convenient location for the worker, the department or self-insurer may make alternate arrangements for the examination including, but not limited to:(1) Considering whether a consultation might be a s…

(1) The following exams may be conducted via telehealth:(a) Mental health;(b) Dermatology;(c) Speech when there is no documented hearing loss;(d) Kidney function;(e) Hematopoietic system;(f) Endocrine.(2) The terms telehealth and telemedicine are used interchangeably and have the…

(1) Workers can bring an adult observer to the IME to provide comfort and reassurance.The accompanying person will not be compensated for attending the examination by the department or self-insured employer. The accompanying person must be unobtrusive at all times. Obtrusive beha…

(1) After receipt of the IME appointment/assignment letter, but no less than seven calendar days before the date of the examination, the worker or their representative must provide written notice to the IME firm or an examiner not in a firm, as listed in the appointment/assignmen…

If notice is received less than seven calendar days prior to the IME, a worker may record the examination only if the IME provider waives the seven calendar day notification requirement. If notification is received after 5:00 p.m., in the time zone of the examination location, th…

Workers can send written complaints about a provider's conduct during an independent medical examination to the self-insurer or department. Based on the nature of the complaint, the department may refer the complaint to the department of health.[Statutory Authority: RCW 51.32.055…

When doing an impairment rating examination, the IME provider must first review the determination by the attending provider that the worker has reached maximum medical improvement (MMI).(1) If, after reviewing the records, taking a history from the worker and performing the exami…

The following table provides guidance regarding the rating systems generally used. These rating systems or others adopted through department policies should be used to conduct an impairment rating.Overview of Systems for Rating ImpairmentRating SystemUsed for These ConditionsForm…

(1) It is the department's intention to purchase objective examinations to ensure that sure and certain determinations are made of all benefits to which the worker might be entitled. The independent medical examination report must:(a) Contain objective, sound and sufficient medic…

IME providers must make themselves reasonably available to testify at the board of industrial insurance appeals (board) or by deposition. Reasonably available to all parties means cooperating in the timely scheduling of the pretestimony conference and testimony and being availabl…

The maximum fee schedule for performing independent medical examinations is published by the department in the Medical Aid Rules and Fee Schedule available from the department.[Statutory Authority: RCW 51.32.055, 51.32.112, 51.32.114, 51.36.060, and 51.36.070. WSR 04-04-029, § 29…

Following receipt of an appeal by any party, the department may reassume and schedule, or may order the self-insured employer to schedule, an examination.The self-insured employer may also schedule an examination regarding an appeal if a request has been approved by the departmen…

The department will regularly provide independent medical examination data to interested parties that includes emerging trends.As much as possible, the data should include and differentiate between examinations for claims insured by the department and those covered by self-insure…

Hospitals may find general information and rules pertaining to the care of workers in chapters 296-20, 296-21 and 296-23 WAC, department bulletins and other department publications. This list is not exhaustive and hospitals remain responsible for other applicable rules.[Statutory…

The department or self-insurer will pay for hospital services when proper and necessary for the treatment of the accepted occupational disease or injury.See WAC 296-20-01002 for the definition of medically necessary.See WAC 296-20-075 for further rules regarding hospitalization.S…

The department uses utilization review criteria and all hospital inpatient and outpatient services and billed charges are subject to review by the department, self-insurer or a representative chosen by the department or self-insurer.[Statutory Authority: RCW 51.04.020, 51.04.030 …

The department will establish and update hospital payment rates, methods and policies in consultation with interested persons at times determined by the department. The department will publish a description of payment methods, rates, and policies for hospital services at least th…

The department will give at least thirty calendar days notice to interested persons who request advance notice of changes to hospital payment rates, methods and policies. Interested persons may request advance notice by contacting the department at the following address:Departmen…

Hospitals must submit bills for hospital services using the current National Uniform Billing Form (billing form), or electronically using department file format specifications. Providers using the paper billing form must follow both the billing instructions provided by the depart…

Hospitals must submit charges for ambulance services and professional services provided by hospital staff physicians on the current Health Insurance Claim Form (as defined by the National Uniform Claim Committee), using the provider account number(s) assigned by the department fo…

Preadmission services performed in a hospital outpatient setting within one day prior to hospital admission must be billed as hospital inpatient services.[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. WSR 97-06-066, § 296-23A-0170, filed 2/28/97, effective 4/1/97.]

Hospitals must send the following supporting documentation for hospital services:•Admission history and physical examination•Discharge summary for stays over forty-eight hours•Emergency room reports•Operative reports•Anesthesia records•Other documentation as requested by the depa…

Do not submit supporting documentation with the bill for services. Hospitals must send supporting documentation for hospital services for state fund claims to:Department of Labor and IndustriesClaims SectionP.O. Box 44291Olympia, WA 98504-4291[Statutory Authority: RCW 51.04.020, …

Providers using any of the electronic transfer options provided by the department must send the department or self-insurer the required supporting documentation within thirty calendar days of the date billing information was sent to the department on electronic medium. Providers …

The department will pay for hospital inpatient services according to the following table:Hospital Type or LocationDo Diagnosis Related Group (DRG) payment methods apply?Do per diem payment methods apply?Do percent of allowed charges (POAC) payment methods apply to hospital inpati…

Self-insurers will pay for hospital inpatient services using percent of allowed charges (POAC) factors, according to the following table:Hospital Type or LocationDo percent of allowed charges (POAC) payment methods apply to hospital inpatient services?Military, Veteran’s Administ…

The department will pay for hospital outpatient services according to the following table:Hospital Type or Service LocationDoes the Ambulatory Payment Classification System apply?Do percent of allowed charges (POAC) payment methods apply?Do the department's Medical Aid Rules and …

The self-insurer will pay for hospital outpatient services according to the following table:Hospital Type or Service LocationDo percent of allowed charges (POAC) payment methods apply?Do the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, …

The department or self-insurer pays out-of-state hospitals for hospital services using a percent of allowed charges (POAC) factor or department fee schedule. The POAC factor may differ for services performed in inpatient and outpatient settings. Payment rates to hospitals located…

New hospitals are those open for less than one year prior to the implementation of the department's most recent hospital payment rates. The department will pay new hospitals according to the following table:Hospital Type or LocationWhat Diagnosis Related Group (DRG) base price ap…

A change in ownership does not constitute the creation of a new hospital. If a hospital changes ownership, rates will remain the same as those payable to the previous owner.[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. WSR 97-06-066, § 296-23A-0250, filed 2/28/97,…

The department may designate from time to time, those hospitals and hospital services to be paid using POAC factors.[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. WSR 97-06-066, § 296-23A-0300, filed 2/28/97, effective 4/1/97.]

POAC factors are based on medicare cost report data and are calculated by dividing adjusted operating expenses by adjusted patient revenues. The department will allow costs for graduate medical education and charity care. Allowable costs for charity care shall not exceed a maximu…

The department may designate from time to time, those hospitals and hospital services paid on a per diem basis. For example, the department may develop per diem rates for the following diagnosis-related-group (DRG) categories:•Psychiatric;•Rehabilitation;•Substance abuse;•Medical…

Per diem rates are calculated by dividing the total costs for all relevant cases in the historical database by the total number of days. The total number of days is equal to the sum of the number of days for each relevant case. The number of days per case is equal to last date of…

A diagnosis-related-group (DRG) system categorizes patients into clinically coherent and homogenous groups with respect to resource use. The department will use an all-patient grouper to perform the diagnostic categorization. To the extent feasible, where DRG relative weights mee…

In calculating DRG relative weights, the department will:(1) Allocate costs for hospital services at a detailed revenue code level using medicare cost report data and medicare definitions for allowable costs. The department will allow costs for graduate medical education and char…

The department determines the base price for hospital services paid using per case rates according to the following table:Type of HospitalBase PriceMajor Teaching Hospital:Harborview Medical Center orUniversity of WashingtonHospital-specific case-mix adjusted average cost per cas…

The department determines the case-mix adjusted average cost per case for each hospital by:(1) Allocating costs for hospital services at a detailed revenue code level using medicare cost report data and medicare definitions for allowable costs. The department will allow costs for…

The department calculates the base price for DRG hospitals, except major teaching hospitals by:(1) Calculating each hospital's case-mix adjusted average cost per case;(2) Weighting each hospital's case-mix adjusted average cost per case by the number of cases at that hospital;(3)…

The department excludes the following types of cases from base price calculations:•Transfers;•Statistical outliers;•Length of stay equal to zero;•Psychiatric, substance abuse and rehabilitation DRGs;•Out-of-state hospitals; and•Other hospitals and services designated as exempt fr…

The DRG per case rate for a particular hospital is calculated by multiplying the assigned DRG relative weight for that admission by the applicable base price.[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. WSR 97-06-066, § 296-23A-0460, filed 2/28/97, effective 4/1/…

The following exclusions and exceptions apply to DRG payments for hospital services:•Psychiatric, rehabilitation, and chemical dependency (substance abuse) services will be excluded from payment by DRG rates. These services will be paid using per diem payment rates.•Ambulance and…

The following hospitals are excluded from DRG payments:•Military, Veterans Administration, state psychiatric facilities, health maintenance organizations (HMO), and children's hospitals will be paid their allowed charges.•Department-approved chronic pain management programs will …

Unless otherwise specified, the department will include in the DRG rate all hospital services provided to an injured worker admitted to a hospital. Hospital services must be medically necessary for the treatment of the accepted occupational disease or injury.[Statutory Authority:…

Outlier payments apply only to diagnosis-related-group (DRG) reimbursed cases with unusually high or low costs. Outlier status does not apply to cases paid using a percent of allowed charges (POAC) factor or per diem rates.A case is considered a high cost outlier if the costs for…

Cases defined as high cost outliers will be reimbursed at the diagnosis-related-group (DRG) payment rate plus one hundred percent of costs in excess of the threshold. Costs are determined by multiplying the allowed charges by the hospital specific percent of allowed charges (POAC…

To qualify as a low outlier, the allowed charges multiplied by that hospital's percent of allowed charges (POAC) factor must be less than ten percent of the statewide diagnosis-related-group (DRG) rate or five hundred dollars whichever is greater. The standard deviations for DRGs…