See WAC 296-20-12095
SIMP referral and prior authorization requirements, for information about how and when each phase may be prior authorized by the claim manager.
The Evaluation phase occurs before the treatment phase and includes treatment plan development and a report. Only one evaluation is allowed per authorization but it can be conducted over one to two days. The evaluation phase includes all of the following components:
(1) A history and physical exam along with a medical evaluation by a physician. Advanced registered nurse practitioners and certified physician assistants can perform those medical portions of the pretreatment evaluation that are allowed by the commission on accreditation of rehabilitation facilities (CARF);
(2) Review of medical records and reports, including diagnostic tests and previous efforts at pain management;
(3) Assessment of any important associated conditions that may hinder recovery (e.g., opioid dependence and other substance use disorders, smoking, significant mental health disorders, and unmanaged chronic disease). If such conditions exist, see WAC 296-20-12095
SIMP referral and prior authorization requirements;
(4) Assessment of past and current use of all pain management medications, including over the counter, prescription, scheduled, and illicit drugs;
(5) Psychological and social assessment by a licensed clinical psychologist using valid tests and instruments;
(6) Identification of the worker's family and support resources;
(7) Identification of the worker's reasons and motivation for participation and improvement;
(8) Identification of factors that may affect participation in the program;
(9) Assessment of pain and function using valid tests and instruments; it should include the current levels, future goals, and the estimated treatment time to achieve them for each of the following areas:
Activities of daily living (ADLs);
Range of motion (ROM);
Capacity for and interest in returning to work.
(10) If the claim manager has assigned a vocational counselor, the SIMP vocational provider must coordinate with the vocational counselor to assess the likelihood of the worker's ability to return to work and in what capacity;
(11) A summary report of the evaluation and a preliminary recommended treatment plan. If there are any barriers preventing the worker from moving on to the treatment phase, the report should explain the circumstances;
(12) For lumbar surgery candidates, the report should address their expectation and interest in having surgery.
[Statutory Authority: RCW 70.14.120, 51.04.020, 51.04.030. 09-20-040, § 296-20-12070, filed 9/30/09, effective 11/1/09.]