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WAC 296-15-450

Agency filings affecting this section

Closure of self-insured claims.

(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, the department may require a self-insurer to pay additional benefits on a claim the self-insurer closed if the self-insurer:
(a) Made an error in benefits paid; or
(b) Violated the conditions of claim closure.
(2) What claims may a self-insurer close?
A self-insurer may close
If the
With time loss?
Other requirements?
With PPD?
Medical only (MO) claims
Claim was filed on or after 07/01/90 and before 08/01/97
Without
None.
Without1
Time loss (TL) claims
Claim was filed on or after 07/01/86 and before 08/01/97
With
1. Not if the department issued an order resolving a dispute; AND
2. Only if the worker returned to work with the employer of record at the same job or at a job with comparable wages and benefits.2
Without1
All claims:
Medical only (MO) claims
Time loss (TL) claims
Permanent partial disability (PPD) claims
Claim was filed on or after 08/01/97
With or without
1. Not if the department issued an order resolving a dispute; AND
2. Only if the worker returned to work with the employer of record at the same job or at a job with comparable wages and benefits;2 AND
3. Only if the closing medical report was sent to the attending or treating doctor and 143 days allowed for response.
With or without
1
A self-insurer may not close a claim with PPD if the injury or illness occurred before 08/01/97.
2
Comparable means the wages and benefits are at least ninety-five percent of the wages and benefits received by the worker at the time of injury.
3
When not specified, time is in calendar days.
(3) When a self-insurer is closing a PPD claim, what must it do with the closing medical report?
When a self-insurer is closing a PPD claim, it must send the closing medical report to the attending or treating doctor, and the doctor must be allowed fourteen days to respond. When the attending or treating doctor responds:
Within 14 days
And the doctor AGREES with
And the doctor DISAGREES with
Then the self-insurer
 
Within
Fixed and stable and PPD rating
 
MAY
Close the claim.
Does not respond
 
 
MAY
Close the claim
Within or before the order is issued
 
Fixed and stable
 
 
MUST
1. Obtain a supplemental medical opinion from (an) examiner(s) listed on the department's approved examiner's list; OR
2. Forward the claim to department for closure. The department may require additional medical examinations.
Within or before the order is issued
Fixed and stable
PPD rating
 
 
MUST
1. Obtain a supplemental medical opinion from (an) examiner(s) listed on the department's approved examiner's list; OR
2. Forward the claim to department for closure. The department may require additional medical examinations.
Not within, after the order is issued, but before the order is final
 
Fixed and stable and/or PPD rating
MUST
Forward the claim including the doctor's response to the department as a protest within five working days of receipt.
(4) What must a self-insurer do with a closing medical report, regardless of who is closing the claim?
A self-insurer must send the closing medical report to the attending or treating doctor. If the doctor responds that he/she does not concur with the results, the self-insurer must:
(a) Obtain a supplemental medical opinion from (an) examiner(s) listed on the department's approved examiner's list in order to do the closing action itself; OR
(b) Forward the claim to department for closure. The department may require additional medical examinations.
(5) When a self-insurer is closing a claim, what written notice must it provide to the worker and attending or treating doctor?
At claim closure, a self-insurer must send the closing order to the worker and attending or treating doctor.
(a) For a MO claim, use a Self-Insurer's Claim Closure Order and Notice substantially similar to F 207-020-111.
(b) For a TL claim, use a Self-Insured Employers' Time Loss Claim Closure Order and Notice substantially similar to F 207-070-000. Include a complete and accurate SIF-5 substantially similar to L&I form F 207-005-000 with the worker's copy.
(c) For a PPD claim:
(i) When no TL or loss of earning power (LOEP) was paid, use a form substantially similar to L&I form F 207-165-000 (MO with PPD). Include a complete and accurate SIF-5 with the worker's copy.
(ii) When TL or LOEP was paid, use a form substantially similar to L&I form F 207-164-000 (TL with PPD). Include a complete and accurate SIF-5 with the worker's copy.
(6) When a self-insurer is closing a claim, what information must it submit to the department?
A self-insurer must submit to the department:
(a) MO claim closures by the end of the month following closure. These may be transferred electronically or reported by paper.
(i) Closures transferred electronically must be in the department's format.
(ii) Closures submitted in paper must include the SIF-2 L&I form F 207-002-000 showing the date of closure and any vocational services provided.
(b) TL and PPD claim closures at the time of closure. Include copies of each of the following:
(i) SIF-2 if not previously submitted.
(ii) Closure order.
Note:
If no one protests the self-insurer's closure order, it will become final and binding in sixty days, just like a department order.
(iii) A PPD Payment Schedule, if necessary, substantially similar to L&I form F 207-162-000.
(A) A payment schedule is required when the amount of the award is more than three times the state's average monthly wage at the date of injury. At initial/down payment, send copies to the worker and the department.
(B) The first payment of the PPD award must be paid within five working days of claim closure. Continuing payments must be paid according to the established payment schedule.
(iv) A complete and accurate SIF-5 showing all requirements for closure have been met, any TL or LOEP paid, period of payment, and total amount paid.
(7) When the department is closing a claim, what must the self-insurer submit when requesting claim closure?
When a self-insurer is asking the department to close the claim, it must submit:
(a) A complete and accurate SIF-5; and
(b) All records not previously submitted to the department excluding bills.
(8) When the department has closed a PPD claim, when must the self-insurer create a payment schedule?
When the department has closed a PPD claim, the self-insurer must create a PPD Payment Schedule substantially similar to L&I form F 207-162-000 when the amount of the award is more than three times the state's average monthly wage at the date of injury. At initial/down payment, send copies to the worker and the department.
(9) When the department has closed a PPD claim, when must the self-insurer make the first payment of the award?
When the department has closed a PPD claim, the self-insurer must make the first payment of the award without delay. Continuing payments must be paid according to the established payment schedule.
[Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. WSR 06-06-066, § 296-15-450, filed 2/28/06, effective 4/1/06. Statutory Authority: RCW 51.32.190(6), 51.32.055 (8)(a) and (9)(a). WSR 98-24-121, § 296-15-450, filed 12/2/98, effective 1/2/99.]