Chapter 296-20 WAC: MEDICAL AID RULES

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WACs > Title 296 > Chapter 296-20

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Chapter 296-20 WAC	Last Update: 5/7/13
MEDICAL AID RULES

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WAC Sections

296-20-010	General information.
296-20-0100	Industrial insurance chiropractic advisory committee.
296-20-01001	Industrial insurance medical advisory committee.
296-20-01002	Definitions.
296-20-01010	Scope of health care provider network.
296-20-01020	Health care provider network enrollment.
296-20-01030	Minimum health care provider network standards.
296-20-01040	Health care provider network continuing requirements.
296-20-01050	Health care provider network further review and denial.
296-20-01060	Delegation of credentialing and recredentialing activities.
296-20-01070	Waiting periods for reapplying to the network.
296-20-01080	Management of the provider network.
296-20-01090	Request for reconsideration of department decision.
296-20-01100	Risk of harm.
296-20-015	Who may treat.
296-20-01501	Physician's assistant rules.
296-20-01505	Provider types and services not covered.
296-20-020	Acceptance of rules and fees.
296-20-02005	Keeping of records.
296-20-02010	Review of health services providers.
296-20-02015	Interest on excess payments.
296-20-022	Payment of out-of-state providers.
296-20-023	Third party settlement -- Excess recoveries.
296-20-024	Utilization management.
296-20-025	Initiating treatment and submitting a claim for benefits.
MEDICAL COVERAGE DECISIONS
296-20-02700	What is a medical coverage decision?
296-20-02701	Who makes medical coverage decisions?
296-20-02702	Who uses medical coverage decisions?
296-20-02703	How can I determine if a specific health care service or supply is the subject of a medical coverage decision?
296-20-02704	What criteria does the director or director's designee use to make medical coverage decisions?
296-20-02705	What are treatment and diagnostic guidelines and how are they related to medical coverage decisions?
296-20-02850	When may the department cover controversial, obsolete, investigational or experimental treatment?
TREATMENT AUTHORIZATION REQUIREMENTS
296-20-030	Treatment not requiring authorization for accepted conditions.
296-20-03001	Treatment requiring authorization.
296-20-03002	Treatment not authorized.
296-20-03004	Chemonucleolysis.
MEDICATION RULES
296-20-03005	Inoculation or immunological treatment for exposure to infectious occupational disease.
296-20-03010	What are the general principles the department uses to determine coverage on drugs and medications?
296-20-03011	What general limitations are in place for medications?
296-20-03012	Where can I find the department's outpatient drug and medication coverage decisions?
296-20-03013	Will the department or self-insurer pay for a denied outpatient drug in special circumstances?
296-20-03014	Which drugs have specific limitations?
296-20-03015	What steps may the department or self-insurer take when concerned about the amount or appropriateness of drugs and medications prescribed to the injured worker?
296-20-03016	Is detoxification and/or chemical dependency treatment covered?
296-20-03017	What information is needed for prescriptions and the physician's record?
296-20-03018	What inpatient drugs are covered?
OPIOIDS FOR NONCANCER PAIN
296-20-03019	Under what conditions will the department or self-insurer pay for oral opioid treatment for chronic, noncancer pain?
296-20-03020	What are the authorization requirements for treatment of chronic, noncancer pain with opioids?
296-20-03021	What documentation is required to be submitted for continued coverage of opioids to treat chronic, noncancer pain?
296-20-03022	How long will the department or self-insurer continue to pay for opioids to treat chronic, noncancer pain?
296-20-03023	When may the department or self-insurer deny payment of opioid medications used to treat chronic, noncancer pain?
296-20-03024	Will the department or self-insurer pay for nonopioid medications for the treatment of chronic, noncancer pain?
296-20-035	Treatment in cases that remain open beyond sixty days.
296-20-045	Consultation requirements.
296-20-051	Consultations.
296-20-055	Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.
296-20-06101	What reports are health care providers required to submit to the insurer?
296-20-065	Transfer of providers.
296-20-071	Concurrent treatment.
296-20-075	Hospitalization.
296-20-081	Unrelated concurrent nonemergent surgery.
296-20-091	Home nursing.
296-20-097	Reopenings.
296-20-09701	Request for reconsideration.
296-20-100	Eye glasses and refractions.
296-20-110	Dental.
296-20-1101	Hearing aids and masking devices.
296-20-1102	Special equipment rental and purchase prosthetic and orthotics equipment.
296-20-1103	Travel expense.
296-20-120	Procedures not listed in this schedule.
296-20-12050	Special programs.
STRUCTURED INTENSIVE MULTIDISCIPLINARY PROGRAM (SIMP) FOR CHRONIC NONCANCER PAIN
296-20-12055	Structured intensive multidisciplinary program (SIMP) for chronic noncancer pain.
296-20-12060	SIMP requirements for lumbar fusion and artificial disc replacement candidates.
296-20-12065	SIMP definitions.
296-20-12070	SIMP evaluation phase.
296-20-12075	SIMP treatment phase.
296-20-12080	SIMP follow-up phase.
296-20-12085	Requirements the SIMP provider must meet.
296-20-12090	Requirements the worker must meet for a SIMP.
296-20-12095	SIMP referral and prior authorization requirements.
296-20-121	X rays.
296-20-124	Rejected and closed claims.
296-20-12401	Application process for providers outside the scope of the provider network.
BILLING
296-20-125	Billing procedures.
296-20-12501	Physician assistant billing procedure.
296-20-132	Determination of conversion factor adjustments.
296-20-135	Conversion factors.
296-20-170	Pharmacy -- Acceptance of rules and fees.
296-20-17001	Allowance and payment for medication.
296-20-17002	Billing.
296-20-17004	Billing and payment for initial prescription drugs.
IMPAIRMENT RATING
296-20-19000	What is a permanent partial disability award?
296-20-19010	Are there different types of permanent partial disabilities?
296-20-19020	How is it determined which impairment rating system is to be used to rate specified and unspecified disabilities?
296-20-19030	To what extent is pain considered in an award for permanent partial disability?
296-20-200	General information for impairment rating examinations by attending doctors, consultants or independent medical examination (IME) providers.
296-20-2010	General rules for impairment rating examinations by attending doctors and consultants.
296-20-2015	What rating systems are used for determining an impairment rating conducted by the attending doctor or a consultant?
296-20-2025	May a worker bring someone with them to an impairment rating examination conducted by the attending doctor or a consultant?
296-20-2030	May the worker videotape or audiotape the impairment rating examination conducted by the attending doctor or a consultant?
296-20-220	Special rules for evaluation of permanent bodily impairment.
296-20-230	Cervical and cervico-dorsal impairments.
296-20-240	Categories of permanent cervical and cervico-dorsal impairments.
296-20-250	Impairments of the dorsal area.
296-20-260	Categories of permanent dorsal area impairments.
296-20-270	Dorso-lumbar and lumbosacral impairments.
296-20-280	Categories of permanent dorso-lumbar and lumbosacral impairments.
296-20-290	Impairments of the pelvis.
296-20-300	Categories of permanent impairments of the pelvis.
296-20-310	Convulsive neurological impairments.
296-20-320	Categories of permanent convulsive neurological impairments.
296-20-330	Impairments of mental health.
296-20-340	Categories for evaluation of permanent impairments of mental health.
296-20-350	Cardiac impairments.
296-20-360	Categories of permanent cardiac impairments.
296-20-370	Respiratory impairments.
296-20-380	Categories of permanent respiratory impairments.
296-20-385	Categories of persisting variable respiratory impairment with normal baseline spirometry.
296-20-390	Air passage impairments.
296-20-400	Categories of permanent air passage impairments.
296-20-410	Nasal septum impairments.
296-20-420	Categories of permanent air passage impairment due to nasal septum perforations.
296-20-430	Loss of taste and smell.
296-20-440	Categories of permanent loss of taste and smell.
296-20-450	Speech impairments.
296-20-460	Categories of permanent speech impairments.
296-20-470	Skin impairments.
296-20-480	Categories of permanent skin impairments.
296-20-490	Impairment of the upper digestive tract, stomach, esophagus or pancreas.
296-20-500	Categories of permanent impairments of the upper digestive tract, stomach, esophagus or pancreas.
296-20-510	Lower digestive tract impairments.
296-20-520	Categories of permanent lower digestive tract impairments.
296-20-530	Impairment of anal function.
296-20-540	Categories of permanent impairments of anal function.
296-20-550	Liver and biliary tract impairments.
296-20-560	Categories of permanent liver and biliary tract impairments.
296-20-570	Impairments of the spleen, loss of one kidney, and surgical removal of the bladder with urinary diversion.
296-20-580	Categories of permanent impairment of the spleen, loss of one kidney, and surgical removal of bladder with urinary diversion.
296-20-590	Impairment of upper urinary tract.
296-20-600	Categories of permanent impairments of upper urinary tract.
296-20-610	Additional permanent impairments of upper urinary tract due to surgical diversion.
296-20-620	Categories of additional permanent impairments of upper urinary tract due to surgical diversion.
296-20-630	Impairment of bladder function.
296-20-640	Categories of permanent impairments of bladder function.
296-20-650	Anatomical or functional loss of testes.
296-20-660	Categories of permanent anatomical or functional loss of testes.
296-20-670	Disability.
296-20-680	Classification of disabilities in proportion to total bodily impairment.
296-20-690	Permanent impairments of the cervico-dorsal (WAC 296-20-240) and lumbosacral regions (WAC 296-20-280) jointly.

DISPOSITIONS OF SECTIONS FORMERLY CODIFIED IN THIS CHAPTER

296-20-01502	When can a physician assistant have sole signature on the report of accident or physician's initial report? [Statutory Authority: 2004 c 65 and 2004 c 163. 04-22-085, § 296-20-01502, filed 11/2/04, effective 12/15/04.] Repealed by 08-04-095, filed 2/5/08, effective 2/22/08. Statutory Authority: 2007 c 263, RCW 51.04.020 and 51.04.030.
296-20-02001	Penalties. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 90-04-057, § 296-20-02001, filed 2/2/90, effective 3/5/90. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-01-100 (Order 80-29), § 296-20-02001, filed 12/23/80, effective 3/1/81; Order 76-34, § 296-20-02001, filed 11/24/76, effective 1/1/77.] Repealed by 02-21-108, filed 10/22/02, effective 12/1/02. Statutory Authority: RCW 51.04.020.
296-20-03003	Drugs and medication. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 86-06-032 (Order 86-19), § 296-20-03003, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), § 296-20-03003, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-03003, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-03003, filed 12/23/80, effective 3/1/81; Order 77-27, § 296-20-03003, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-03003, filed 11/24/76, effective 1/1/77.] Repealed by 00-01-040, filed 12/7/99, effective 1/20/00. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-040	Modalities not requiring prior authorization after sixty days. [Order 68-7, § 296-20-040, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71.
296-20-050	Periodical clinical reports. [Order 68-7, § 296-20-050, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-061.
296-20-060	Fees for concurrent treatment. [Order 68-7, § 296-20-060, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-071.
296-20-061	Periodic clinical progress reports. [Order 71-6, § 296-20-061, filed 6/1/71; Order 70-12, § 296-20-061, filed 12/1/70, effective 1/1/71. Formerly WAC 296-20-050.] Repealed by Order 74-39, filed 11/22/74.
296-20-070	Consultations. [Order 68-7, § 296-20-070, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-051.
296-20-080	Private room -- Special nurses. [Order 68-7, § 296-20-080, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-091.
296-20-085	Isolation of infected cases. [Order 71-6, § 296-20-085, filed 6/1/71; Order 70-12, § 296-20-085, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-085, filed 11/27/68, effective 1/1/69.] Repealed by 81-01-100 (Order 80-29), filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3).
296-20-090	Reopenings. [Order 68-7, § 296-20-090, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-097.
296-20-095	Unrelated elective surgery. [Order 68-7, § 296-20-095, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71. Later promulgation, see WAC 296-20-081.
296-20-105	Laboratory. [Order 68-7, § 296-20-105, filed 11/27/68, effective 1/1/69.] Repealed by Order 70-12, filed 12/1/70, effective 1/1/71.
296-20-115	Flat fees. [Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-01-100 (Order 80-29), § 296-20-115, filed 12/23/80, effective 3/1/81; Order 71-6, § 296-20-115, filed 6/1/71; Order 70-12, § 296-20-115, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-115, filed 11/27/68, effective 1/1/69.] Repealed by 93-16-072, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159.
296-20-12502	Physician assistant modifiers. [Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-12502, filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), § 296-20-12502, filed 12/23/80, effective 3/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-12502, filed 11/30/79, effective 1/1/80.] Repealed by 93-16-072, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159.
296-20-130	Medical aid contracts. [Order 74-7, § 296-20-130, filed 1/30/74; Order 70-12, § 296-20-130, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-130, filed 11/27/68, effective 1/1/69.] Repealed by Order 77-27, filed 11/30/77, effective 1/1/78.
296-20-131	Advance authorization required for nonstandard treatment. [Order 74-7, § 296-20-131, filed 1/30/74.] Repealed by Order 76-34, filed 11/24/76, effective 1/1/77.
296-20-140	Conversion factor table -- Anesthesia. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 87-03-004 (Order 86-45), § 296-20-140, filed 1/8/87; 83-24-016 (Order 83-35), § 296-20-140, filed 11/30/83, effective 1/1/84; 82-24-050 (Order 82-39), § 296-20-140, filed 11/29/82, effective 7/1/83. Statutory Authority: RCW 51.04.020(4),51.04.030 , and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-140, filed 11/30/81, effective 1/1/82; 80-18-033 (Order 80-24), § 296-20-140, filed 12/1/80, effective 1/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-140, filed 11/30/79, effective 1/1/80; Order 77-27, § 296-20-140, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-140, filed 11/24/76, effective 1/1/77; Order 75-39, § 296-20-140, filed 11/28/75, effective 1/1/76; Order 74-39, § 296-20-140, filed 11/22/74, effective 4/1/75; Order 74-7, § 296-20-140, filed 1/30/74.] Repealed by 88-24-011 (Order 88-28), filed 12/1/88, effective 1/1/89. Statutory Authority: RCW 51.04.020(4) and 51.04.030.
296-20-14001	Conversion factor table -- Hospital. [Order 75-39, § 296-20-14001, filed 11/28/75, effective 1/1/76.] Repealed by Order 76-34, filed 11/24/76, effective 1/1/77.
296-20-145	Conversion factor table -- Surgery. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 87-03-004 (Order 86-45), § 296-20-145, filed 1/8/87; 83-24-016 (Order 83-35), § 296-20-145, filed 11/30/83, effective 1/1/84; 82-24-050 (Order 82-39), § 296-20-145, filed 11/29/82, effective 7/1/83. Statutory Authority: RCW 51.04.020(4),51.04.030 , and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-145, filed 11/30/81, effective 1/1/82; 80-18-033 (Order 80-24), § 296-20-145, filed 12/1/80, effective 1/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-145, filed 11/30/79, effective 1/1/80; Order 77-27, § 296-20-145, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-145, filed 11/24/76, effective 1/1/77; Order 75-39, § 296-20-145, filed 11/28/75, effective 1/1/76; Order 74-7, § 296-20-145, filed 1/30/74.] Repealed by 88-24-011 (Order 88-28), filed 12/1/88, effective 1/1/89. Statutory Authority: RCW 51.04.020(4) and 51.04.030.
296-20-150	Conversion factor table -- Radiology. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 87-03-004 (Order 86-45), § 296-20-150, filed 1/8/87; 83-24-016 (Order 83-35), § 296-20-150, filed 11/30/83, effective 1/1/84. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-150, filed 11/30/81, effective 1/1/82; 80-18-033 (Order 80-24), § 296-20-150, filed 12/1/80, effective 1/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-150, filed 11/30/79, effective 1/1/80; Order 77-27, § 296-20-150, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-150, filed 11/24/76, effective 1/1/77; Order 75-39, § 296-20-150, filed 11/28/75, effective 1/1/76; Order 74-7, § 296-20-150, filed 1/30/74.] Repealed by 88-24-011 (Order 88-28), filed 12/1/88, effective 1/1/89. Statutory Authority: RCW 51.04.020(4) and 51.04.030.
296-20-155	Conversion factor table -- Pathology. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 87-03-004 (Order 86-45), § 296-20-155, filed 1/8/87; 83-24-016 (Order 83-35), § 296-20-155, filed 11/30/83, effective 1/1/84. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-155, filed 11/30/81, effective 1/1/82; 80-18-033 (Order 80-24), § 296-20-155, filed 12/1/80, effective 1/1/81. Statutory Authority: RCW 51.04.030 and 51.16.035. 79-12-086 (Order 79-18), § 296-20-155, filed 11/30/79, effective 1/1/80; Order 77-27, § 296-20-155, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-155, filed 11/24/76, effective 1/1/77; Order 74-7, § 296-20-155, filed 1/30/74.] Repealed by 88-24-011 (Order 88-28), filed 12/1/88, effective 1/1/89. Statutory Authority: RCW 51.04.020(4) and 51.04.030.
296-20-17003	Fees. [Statutory Authority: RCW 51.04.020(4) and 51.04.030. 83-24-016 (Order 83-35), § 296-20-17003, filed 11/30/83, effective 1/1/84. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 80-18-033 (Order 80-24), § 296-20-17003, filed 12/1/80, effective 1/1/81; Order 77-27, § 296-20-17003, filed 11/30/77, effective 1/1/78; Order 76-34, § 296-20-17003, filed 11/24/76, effective 1/1/77.] Repealed by 95-16-031, filed 7/21/95, effective 8/22/95. Statutory Authority: RCW 51.04.030, 70.14.050 and 51.04.020(4).
296-20-210	General rules. [Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.112, 51.32.114 and 51.36.015. 97-09-036, § 296-20-210, filed 4/14/97 effective 5/15/97. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 88-14-012 (Order 88-09), § 296-20-210, filed 6/24/88; Order 74-32, § 296-20-210, filed 6/21/74, effective 10/1/74.] Repealed by 04-04-029, filed 1/27/04, effective 3/1/04. Statutory Authority: RCW 51.32.055, 51.32.112, 51.32.114, 51.36.060, and 51.36.070.
296-20-303	Attendant services. [Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.060, 51.32.072, and 7.68.070. 01-18-041, § 296-20-303, filed 8/29/01, effective 10/1/01.] Decodified by 03-21-069, filed 10/14/03, effective 12/1/03. Statutory Authority: RCW 51.04.020. Recodified as WAC 296-23-246.