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Chapter 296-20 WAC

Last Update: 5/28/13

MEDICAL AID RULES

WAC Sections

General information.
Industrial insurance chiropractic advisory committee.
Industrial insurance medical advisory committee.
Definitions.
Scope of health care provider network.
Health care provider network enrollment.
Minimum health care provider network standards.
Health care provider network continuing requirements.
Health care provider network further review and denial.
Delegation of credentialing and recredentialing activities.
Waiting periods for reapplying to the network.
Management of the provider network.
Request for reconsideration of department decision.
Risk of harm.
Who may treat.
Physician's assistant rules.
Provider types and services not covered.
Acceptance of rules and fees.
Keeping of records.
Review of health services providers.
Interest on excess payments.
Payment of out-of-state providers.
Third party settlement—Excess recoveries.
Utilization management.
Initiating treatment and submitting a claim for benefits.
MEDICAL COVERAGE DECISIONS
What is a medical coverage decision?
Who makes medical coverage decisions?
Who uses medical coverage decisions?
How can I determine if a specific health care service or supply is the subject of a medical coverage decision?
What criteria does the director or director’s designee use to make medical coverage decisions?
What are treatment and diagnostic guidelines and how are they related to medical coverage decisions?
When may the department cover controversial, obsolete, investigational or experimental treatment?
TREATMENT AUTHORIZATION REQUIREMENTS
Treatment not requiring authorization for accepted conditions.
Treatment requiring authorization.
Treatment not authorized.
Chemonucleolysis.
MEDICATION RULES
Inoculation or immunological treatment for exposure to infectious occupational disease.
What are the general principles the department uses to determine drug coverage?
What general limitations are in place for drugs?
Where can I find the department's outpatient drug coverage decisions?
Will the department or self-insurer pay for a denied outpatient drug in special circumstances?
Which drugs have specific limitations?
What steps may the department or self-insurer take when concerned about the amount or appropriateness of drugs prescribed for the injured worker?
What information is needed for prescriptions and the physician’s record?
What inpatient drugs are covered?
OPIOIDS FOR NONCANCER PAIN
Definitions associated with opioid authorization and payment.
Checking the prescription monitoring program data base.
Administering urine drug testing.
Tracking function and pain.
Preinjury opioid use.
Opioid authorization requirement for the acute phase (0-6 weeks).
Opioid authorization requirement for the subacute phase (6-12 weeks).
Opioid authorization requirement for the chronic phase (˃ 12 weeks).
Opioid authorization requirement for ongoing chronic opioid therapy.
Opioid authorization requirement for catastrophic injuries.
Episodic care for pain.
Managing surgical pain in workers on opioid therapy.
When opioid prescribing is not proper and necessary care.
When to discontinue opioids.
Weaning or detoxification.
Addiction treatment.
Treatment in cases that remain open beyond sixty days.
Consultation requirements.
Consultations.
Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.
What reports are health care providers required to submit to the insurer?
Transfer of providers.
Concurrent treatment.
Hospitalization.
Unrelated concurrent nonemergent surgery.
Home nursing.
Reopenings.
Request for reconsideration.
Eye glasses and refractions.
Dental.
Hearing aids and masking devices.
Special equipment rental and purchase prosthetic and orthotics equipment.
Travel expense.
Procedures not listed in this schedule.
Special programs.
STRUCTURED INTENSIVE MULTIDISCIPLINARY
PROGRAM (SIMP) FOR CHRONIC NONCANCER PAIN
Structured intensive multidisciplinary program (SIMP) for chronic noncancer pain.
SIMP requirements for lumbar fusion and artificial disc replacement candidates.
SIMP definitions.
SIMP evaluation phase.
SIMP treatment phase.
SIMP follow-up phase.
Requirements the SIMP provider must meet.
Requirements the worker must meet for a SIMP.
SIMP referral and prior authorization requirements.
X rays.
Rejected and closed claims.
Application process for providers outside the scope of the provider network.
BILLING
Billing procedures.
Physician assistant billing procedure.
Determination of conversion factor adjustments.
Conversion factors.
Pharmacy—Acceptance of rules and fees.
Allowance and payment for medication.
Billing.
Billing and payment for initial prescription drugs.
IMPAIRMENT RATING
What is a permanent partial disability award?
Are there different types of permanent partial disabilities?
How is it determined which impairment rating system is to be used to rate specified and unspecified disabilities?
To what extent is pain considered in an award for permanent partial disability?
General information for impairment rating examinations by attending doctors, consultants or independent medical examination (IME) providers.
General rules for impairment rating examinations by attending doctors and consultants.
What rating systems are used for determining an impairment rating conducted by the attending doctor or a consultant?
May a worker bring someone with them to an impairment rating examination conducted by the attending doctor or a consultant?
May the worker videotape or audiotape the impairment rating examination conducted by the attending doctor or a consultant?
Special rules for evaluation of permanent bodily impairment.
Cervical and cervico-dorsal impairments.
Categories of permanent cervical and cervico-dorsal impairments.
Impairments of the dorsal area.
Categories of permanent dorsal area impairments.
Dorso-lumbar and lumbosacral impairments.
Categories of permanent dorso-lumbar and lumbosacral impairments.
Impairments of the pelvis.
Categories of permanent impairments of the pelvis.
Convulsive neurological impairments.
Categories of permanent convulsive neurological impairments.
Impairments of mental health.
Categories for evaluation of permanent impairments of mental health.
Cardiac impairments.
Categories of permanent cardiac impairments.
Respiratory impairments.
Categories of permanent respiratory impairments.
Categories of persisting variable respiratory impairment with normal baseline spirometry.
Air passage impairments.
Categories of permanent air passage impairments.
Nasal septum impairments.
Categories of permanent air passage impairment due to nasal septum perforations.
Loss of taste and smell.
Categories of permanent loss of taste and smell.
Speech impairments.
Categories of permanent speech impairments.
Skin impairments.
Categories of permanent skin impairments.
Impairment of the upper digestive tract, stomach, esophagus or pancreas.
Categories of permanent impairments of the upper digestive tract, stomach, esophagus or pancreas.
Lower digestive tract impairments.
Categories of permanent lower digestive tract impairments.
Impairment of anal function.
Categories of permanent impairments of anal function.
Liver and biliary tract impairments.
Categories of permanent liver and biliary tract impairments.
Impairments of the spleen, loss of one kidney, and surgical removal of the bladder with urinary diversion.
Categories of permanent impairment of the spleen, loss of one kidney, and surgical removal of bladder with urinary diversion.
Impairment of upper urinary tract.
Categories of permanent impairments of upper urinary tract.
Additional permanent impairments of upper urinary tract due to surgical diversion.
Categories of additional permanent impairments of upper urinary tract due to surgical diversion.
Impairment of bladder function.
Categories of permanent impairments of bladder function.
Anatomical or functional loss of testes.
Categories of permanent anatomical or functional loss of testes.
Disability.
Classification of disabilities in proportion to total bodily impairment.
Permanent impairments of the cervico-dorsal (WAC 296-20-240) and lumbosacral regions (WAC 296-20-280) jointly.
DISPOSITION 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. WSR 04-22-085, § 296-20-01502, filed 11/2/04, effective 12/15/04.] Repealed by WSR 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. WSR 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). WSR 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 WSR 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. WSR 86-06-032 (Order 86-19), § 296-20-03003, filed 2/28/86, effective 4/1/86; WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-03003, filed 11/30/81, effective 1/1/82; WSR 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 WSR 00-01-040, filed 12/7/99, effective 1/20/00. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03016
Is detoxification and/or chemical dependency treatment covered? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03016, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03019
Under what conditions will the department or self-insurer pay for oral opioid treatment for chronic, noncancer pain? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03019, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03020
What are the authorization requirements for treatment of chronic, noncancer pain with opioids? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03020, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03021
What documentation is required to be submitted for continued coverage of opioids to treat chronic, noncancer pain? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03021, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03022
How long will the department or self-insurer continue to pay for opioids to treat chronic, noncancer pain? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03022, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03023
When may the department or self-insurer deny payment of opioid medications used to treat chronic, noncancer pain? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03023, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. Statutory Authority: RCW 51.04.020 and 51.04.030.
296-20-03024
Will the department or self-insurer pay for nonopioid medications for the treatment of chronic, noncancer pain? [Statutory Authority: RCW 51.04.020 and 51.04.030. WSR 00-01-040, § 296-20-03024, filed 12/7/99, effective 1/20/00.] Repealed by WSR 13-12-024, filed 5/28/13, effective 7/1/13. 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 WSR 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). WSR 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 WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-12502, filed 11/30/81, effective 1/1/82; WSR 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. WSR 79-12-086 (Order 79-18), § 296-20-12502, filed 11/30/79, effective 1/1/80.] Repealed by WSR 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. WSR 87-03-004 (Order 86-45), § 296-20-140, filed 1/8/87; WSR 83-24-016 (Order 83-35), § 296-20-140, filed 11/30/83, effective 1/1/84; WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-140, filed 11/30/81, effective 1/1/82; WSR 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. WSR 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 WSR 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. WSR 87-03-004 (Order 86-45), § 296-20-145, filed 1/8/87; WSR 83-24-016 (Order 83-35), § 296-20-145, filed 11/30/83, effective 1/1/84; WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-145, filed 11/30/81, effective 1/1/82; WSR 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. WSR 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 WSR 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. WSR 87-03-004 (Order 86-45), § 296-20-150, filed 1/8/87; WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-150, filed 11/30/81, effective 1/1/82; WSR 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. WSR 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 WSR 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. WSR 87-03-004 (Order 86-45), § 296-20-155, filed 1/8/87; WSR 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). WSR 81-24-041 (Order 81-28), § 296-20-155, filed 11/30/81, effective 1/1/82; WSR 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. WSR 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 WSR 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. WSR 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). WSR 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 WSR 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. WSR 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. WSR 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 WSR 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. WSR 01-18-041, § 296-20-303, filed 8/29/01, effective 10/1/01.] Decodified by WSR 03-21-069, filed 10/14/03, effective 12/1/03. Statutory Authority: RCW 51.04.020. Recodified as § 296-23-246.