Title of Rule:

Amendments to:		Statutory Authority:
WAC 296-30-080	Counseling for sexual assault	RCW 7.68.030, 7.68.070(12)
WAC 296-30-081	Acceptance of rules and fees for medical and mental health services	RCW 7.68.030, 7.68.060, 7.68.080
WAC 296-30-120	Factors considered in order to modify debt due department	RCW 7.68.030, 7.68.120
WAC 296-30-170	Payment for medical examination of victims of sexual assault	RCW 7.68.030, 7.68.170
WAC 296-30-180	Payment of benefits to prevent unjust enrichment	RCW 7.68.030, 7.68.070(15), 7.68.120
WAC 296-31-030	General provider requirements - who may treat	RCW 7.68.030, 7.68.080
WAC 296-31-070	Provider obligations - acceptance of rules and fees	RCW 7.68.030, 7.68.060, 7.68.080
New sections:
WAC 296-30-085	What is different about billing for a crime victim client?	RCW 7.68.030, 7.68.080, 7.68.130
WAC 296-30-090	What are the maximum allowable fees?	RCW 7.68.030, 7.68.080, 7.68.130
WAC 296-30-095	How do the rules and fees apply to out-of-state providers?	RCW 7.68.030
WAC 296-30-100	Will the department notify providers if a fee schedule is amended or established?	RCW 7.68.030
WAC 296-30-105	What protest or appeal rights are available?	RCW 7.68.030, 7.68.110, 51.52.050, 51.52.060(1)
WAC 296-31-035	How do I register to become an authorized provider with the crime victims compensation program?	RCW 7.68.030, 7.68.080
WAC 296-31-045	Can the department deny, revoke, suspend or impose conditions on a provider’s authorization to treat crime victim claimants?	RCW 7.68.030, 7.68.080, 7.68.100
WAC 296-31-055	What type of corrective action can be taken against providers?	RCW 7.68.030, 7.68.080, 7.68.100, 51.48.080, 51.48.250, 51.48.260, 51.48.280, 51.48.290
WAC 296-31-056	Can providers be charged interest on incorrect or inappropriate payments?	RCW 7.68.030, 7.68.080, 51.48.250, 51.48.260
WAC 296-31-057	Can the department penalize a provider?	RCW 7.68.030, 7.68.080, 7.68.100, 51.48.060, 51.48.080, 51.48.090, 51.48.250, 51.48.260, 51.48.270, 51.48.280, 51.48.290
WAC 296-31-058	What protest and appeal rights are available?	RCW 7.68.030, 7.68.110, 51.52.050, 51.52.060(1)
WAC 296-31-074	What if my patient has an unrelated condition?	RCW 7.68.030
Repealed sections:
WAC 296-31-050	Initial treatment and application for benefits
WAC 296-31-090	Mental health fees

Purpose: The rules are being rewritten in language that will be clearer to our customers. New sections were added to separate multiple topics that were covered under one rule. Once the information was rewritten and separated out, two rules were left with obsolete or unnecessary information and are being repealed.

Statutory Authority for Adoption: See Title of Rule above.

Statute Being Implemented: RCW 7.68, Crime Victims Act.

Summary: In connection with the Governor's Executive Order 97-02 on regulatory improvement, the crime victims compensation program is conducting an intensive review of its administrative rules. These proposed amendments clarify language without changing the effect.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Cletus Nnanabu, 7273 Linderson Way, Tumwater, WA, (360) 902-5340.

Name of Proponent: Department of Labor and Industries, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: These rules are the second segment of rules the crime victims compensation program will be rewriting under an intensive rule review in connection with the Governor's Executive Order 97-02 on regulatory improvements. The conclusion following intensive review was that the rules could be rewritten to be clearer to victims and to service providers. Many of the rules had multiple topics which were separated out into new sections. There are no changes in regulations. The purpose and anticipated effect will be that the rules are easier to understand to all parties.

Proposal does not change existing rules.

July 30, 1999

Gary Moore

Director

OTS-2923.3

AMENDATORY SECTION(Amending WSR 94-02-015, filed 12/23/93, effective 1/24/94)

WAC 296-30-080
((Counseling for sexual assault.)) Can family members of sexual assault victims receive counseling?

(((1) Pursuant to RCW 7.68.070(12), the department shall pay for counseling for victims of sexual assault and, when appropriate, for members of a victim's immediate family.  An immediate family member shall be defined as the victim's parents, spouse, child(ren), siblings, grandparents, and those members of the same household who have assumed the rights and duties commonly associated with a family and who hold themselves out as a family unit.

(2) Counseling for the above defined family members is appropriate when:

(a) The counseling is for the spouse, child, parent, or sibling of the victim who suffers psychological trauma as a result of the sexual assault; or

(b) The family member and victim live in the same household and the family member suffers psychological trauma as a result of the sexual assault; or

(c) The family member sees the assault; or

(d) Counseling of the family member will aid in the victim's recovery.)) (1) Counseling for immediate family members of sexual assault victims is appropriate when:

(a) The family member suffers psychological trauma as a result of the sexual assault;

(b) Counseling the family member will help the client's recovery.

(2) Immediate family members are the client's parents, spouse, child(ren), siblings, grandparents, and those members of the same household who have assumed the rights and duties commonly associated with a family unit.

(3) Counseling for immediate family members will be covered under the victim's sexual assault claim.

[Statutory Authority: RCW 7.68.  94-02-015, § 296-30-080, filed 12/23/93, effective 1/24/94; 86-01-028 (Order 85-37), § 296-30-080, filed 12/11/85; 85-03-060 (Order 85-3), § 296-30-080, filed 1/15/85.]

((Providing medical or counseling services to an injured crime victim whose claim for crime victims compensation benefits has been accepted by the department constitutes acceptance of the department's medical aid rules and compliance with its rules and fees.  Maximum allowable fees shall be those fees contained in the publications entitled Medical Aid Rules and Fee Schedules and Crime Victims Compensation Program Mental Health Treatment Rules and Fees, less any available benefits of public or private collateral resources, except as follows:

The percent of allowed charges authorized for hospital inpatient and outpatient services billed by revenue code are those rates established by the department of social and health services under Title 74 RCW and WAC 388-550-4500 (1)(a) and 388-550-6000 (1)(a).

If any of the maximum allowable fees in the publications entitled Medical Aid Rules and Fee Schedules and Crime Victims Compensation Program Mental Health Treatment Rules and Fees is lower than the maximum allowable fees for those procedures established by the department of social and health services under Title 74 RCW, the Title 74 RCW fees are the maximum allowable fees for those procedures.

Prior to the establishment or amendment of the fee schedules, the department will give at least thirty calendar days notice by mail to interested persons who have made timely request for advance notice of the establishment or amendment of the fee schedules.  To request advance notice of the establishment or amendment of the medical fee schedules, interested persons must contact the department at the following address:

Department of Labor and Industries

Health Services Analysis

P.O. Box 44322

Olympia, WA 98504-4322

To request advance notice of the establishment or amendment of the mental health fee schedules, interested persons must contact the department at the following address:

Department of Labor and Industries

Crime Victims Compensation Section

P.O. Box 44520

Olympia, WA 98504-4520

An injured victim shall not be billed for his or her accepted injury.  The department shall be billed only after available benefits of public or private insurance have been determined.  Bills must be submitted within ninety days from the date of service to be considered for payment.  If insurance or public agency collateral resources exist, bills must be received within ninety days following payment or rejection by the resource.  A copy of the payment or rejection must accompany the bill.

If the service provider has billed the injured victim and is later notified that the department has accepted the victim's claim, the provider shall refund to the injured victim any amounts paid, and bill the department for services rendered at their usual and customary fees if such rates are in excess of the public or private insurance entitlements.

On claims closed over ninety days, the department will pay for completion of a reopening application (Code 1041M), an office visit and diagnostic studies necessary to complete the application. No other benefits will be paid until the adjudication decision is rendered. When reopening is granted, the department can pay benefits for a period not to exceed sixty days prior to the date the reopening application is received by the department.

Providers outside of the state of Washington are subject to the same requirements, and are paid the same fees, as providers inside the state, with the exception of independent medical or mental health examinations, which will be paid at the examiner's usual customary fee.)) (1) When treating a crime victim who comes under our jurisdiction, you agree to accept and comply with the department's rules and fees.

(a) Medical providers must comply with this chapter and the department's medical aid rules and fee schedules.

(b) Mental health providers must comply with this chapter and the Crime Victims Compensation Programs Mental Health Treatment Rules and Fees.

(2) You must inform the victim of his or her rights under the Crime Victims Act and give whatever assistance is necessary for the victim to apply for compensation and provide proof of other matters required by our rules. Providers may not charge the victim for these services.

[Statutory Authority: RCW 7.68.030, RCW 7.68.080, RCW 7.68.120, RCW 51.36.010, RCW 51.04.020 (1) and (4) and RCW 51.04.030.   WSR 99-07-004, § 296-30-081, filed 3/4/99, effective 4/4/99.  Statutory Authority: RCW 51.36.010, RCW 7.68.030, RCW 51.04.020 (1) and (4), RCW 51.04.030, RCW 7.68.080 and RCW 7.68.120.  97-02-090, § 296-30-081, filed 12/31/96, effective 1/31/97.  Statutory Authority: RCW 7.68.030, RCW 51.04.020(1) and RCW 51.04.030.  95-15-004, § 296-30-081, filed 7/5/95, effective 8/5/95.  Statutory Authority: RCW 7.68.  94-02-015, § 296-30-081, filed 12/23/93, effective 1/24/94; 92-23-034, § 296-30-081, filed 11/13/92, effective 12/14/92; 92-16-033, § 296-30-081, filed 7/30/92, effective 8/30/92; 86-01-028 (Order 85-37), § 296-30-081, filed 12/11/85.]

(1) Providers must qualify as approved providers and register with the crime victims compensation program before they are authorized to provide treatment and receive payment. To register with the crime victims compensation program, you must send us:

(a) A completed provider application and Form W-9.

(b) A legible copy of your professional license, certification and/or registration.

(c) Ph.Ds not licensed as psychologists and master level counselors must provide a legible copy of their degree.

(2) Providers must determine if any public or private insurance benefits are available before billing the department. Available public or private insurance must be billed first and a copy of the insurance explanation of benefits must be attached to billings submitted to the department.

(3) A client must not be billed for treatment of his or her accepted condition. All copayments, deductibles or out of pocket expenses not covered by primary insurance should be included in your billings to the department.

EXCEPTION:

A provider may require the client to pay for treatment if the client's eligibility is in question (e.g., when an investigation or claim determination is pending). If the claim is subsequently allowed, the provider must refund the client in full and bill us at their usual and customary fees if such rates are in excess of the public or private insurance entitlements.

(4) On claims closed over ninety days, we will pay for completion of a reopening application, an office visit and diagnostic studies necessary to complete the application. No other benefits will be paid until the reopening decision is made. If the reopening application is approved, we can pay benefits for a period not to exceed sixty days prior to the date the reopening application was received by us.

[]

(1) Maximum allowable fees for medical services are those fees published in the Medical Aid Rules and Fee Schedules less any available benefits of public or private insurance.

(2) Maximum allowable fees for mental health services are those fees published in the Crime Victims Compensation Program Mental Health Treatment Rules and Fees less any available benefits of public or private insurance.

EXCEPTION:

If any of the maximum allowable fees in the publications entitled Medical Aid Rules and Fee Schedules and Crime Victims Compensation Program Mental Health Treatment Rules and Fees are lower than the maximum allowable fees for those procedures established by the department of social and health services under Title 74 RCW, the Title 74 RCW fees are the maximum allowable fees for those procedures.

(3) The percent of allowed charges authorized for hospital inpatient and outpatient services billed by revenue codes are those rates established by the department of social and health services under Title 74 RCW and WAC 388-550-4500 (1)(a) and 388-550-6000 (1)(a) less any available benefits of public or private insurance.

[]

Rules and fees are the same for out-of-state providers as for in state providers.

EXCEPTION:

Out-of-state independent medical or mental health examinations are reimbursed at the examiners usual and customary fee.

[]

We will give you at least thirty days advance notice by mail when we amend or establish a fee schedule.

[]

If you or the client do not agree with our order, decision or award a written protest may be sent to the crime victims compensation program or appeal to the board of industrial insurance appeals. A protest or appeal to our order or decision requiring repayment by a provider must be received within twenty days from receipt of the order or decision. A protest or appeal regarding other issues must be received within ninety days of receipt of the order or decision.

Note:

Protest and appeal rights are governed under RCW 51.52 and RCW 7.68.110.

[]

(( RCW 7.68.120 allows the department in the interest of justice or rehabilitation, to waive, modify, or adjust the debt owed to the department by any person found to have committed the criminal act for which crime victim benefits were paid.  To determine whether or not the debt should be modified, waived or adjusted, the department shall consider the following factors:

(1) The gravity of the offense;

(2) Extent of injury to victim;

(3) Type of crime;

(4) Circumstances surrounding the criminal act;

(5) The assailant's attempts at rehabilitation:

(a) Rehabilitation program involvement;

(b) Employment efforts;

(c) Community involvement;

(6) Ability to pay:

(a) Income;

(b) Necessary expenses;

(c) Number and ages of dependents;

(7) Sentence imposed by the court;

(8) The impact on the victim of reducing the debt.)) Yes, the department may consider the following issues in the decision. The list is not inclusive.

(1) Justice:

(a) Gravity of the criminal offense;

(b) History of criminal convictions;

(c) Type of crime;

(d) Circumstances surrounding the criminal act;

(e) Sentence imposed by the court.

(2) Well-being of the victim:

(a) Extent of injury to victim;

(b) Safety of victim;

(c) Dependency of the victim on the offender;

(d) Recovery of victim.

(3) Rehabilitation of the individual:

(a) Attempts at rehabilitation;

(b) Employment status;

(c) Ability to pay.

[Statutory Authority: RCW 51.36.010, RCW 7.68.030, RCW 51.04.020 (1) and (4), RCW 51.04.030, RCW 7.68.080 and RCW 7.68.120.  97-02-090, § 296-30-120, filed 12/31/96, effective 1/31/97.  Statutory Authority: RCW 7.68.  86-01-028 (Order 85-37), § 296-30-120, filed 12/11/85.]

((A victim of sexual assault is entitled to payment for the costs of a medical examination under RCW 7.68.170 regardless of whether she or he qualifies for benefits under RCW 7.68, if the hospital or emergency medical facility proves to the department that:

(1) The care was provided; and

(2) The examination was performed at least in part to gather medical evidence for possible prosecution of the assailant.)) When a sexual assault examination is performed for the purpose of gathering evidence for possible prosecution, the costs of the examination must be billed to the crime victims compensation program. We are the primary payer of this benefit. The client is not required to file an application with us to receive this benefit and may not be billed for these costs. If the examination includes treatment costs or the client will require follow-up treatment, an application for benefits must be filed with us for these services to be considered for payment.

[Statutory Authority: RCW 7.68.  86-01-028 (Order 85-37), § 296-30-170, filed 12/11/85; 85-03-060 (Order 85-3), § 296-30-170, filed 1/15/85.]

(( RCW 7.68.070(15) prohibits the department from paying any benefits or compensation to the person who caused a crime victim's injuries, or to any other person if that person would be unjustly enriched by the benefits.  In some situations, as when a child is injured by a parent or a spouse by the other spouse, there is a danger that the injuring person will divert to his or her own use the benefits or compensation intended for the victim.

To prevent this possibility, the department may on its own motion or the motion of the victim or his or her guardian, request that the victim or other responsible adult establish (1) a trust for which the trustee shall be a neutral third person; or (2) a savings or checking account for which a neutral third person must cosign all withdrawals or checks.  Crime victims compensation benefits shall then be deposited in the established account.

The department shall continue to pay medical providers directly.)) (1) The Crime Victims Act prohibits the department from paying benefits or compensation to a person:

(a) Who caused the crime victim's injuries; or

(b) Any person who would be unjustly enriched by the victim's benefits (e.g., there is a danger the person may divert benefits intended for the victim to his or her own use).

(2) To prevent unjust enrichment, the department, victim, or the victim's guardian may file a motion to:

(a) Request that the victim or other responsible adult establish:

(i) A trust account with a neutral third party as trustee; or

(ii) A savings or checking account with a neutral third party to cosign all withdrawals or checks.

(b) Crime victim compensation benefits will then be deposited in the established account.

(3) The department will continue to pay providers directly.

[Statutory Authority: RCW 51.36.010, RCW 7.68.030, RCW 51.04.020 (1) and (4), RCW 51.04.030, RCW 7.68.080 and RCW 7.68.120.  97-02-090, § 296-30-180, filed 12/31/96, effective 1/31/97.  Statutory Authority: RCW 7.68.  86-01-028 (Order 85-37), § 296-30-180, filed 12/11/85.]

OTS-2922.3

AMENDATORY SECTION(Amending WSR 95-15-004, filed 7/5/95, effective 8/5/95)

WAC 296-31-030
((General provider requirements--Who may treat.)) What are the eligibility requirements of a mental health treatment provider under the Crime Victims Act?

(1) Mental health providers ((who may treat claimants under the Crime Victims Act must register with the crime victims compensation program and qualify as an approved provider under these rules.  The department must register the mental health provider before the mental health provider is eligible for payment for services.

(2) Washington permanently licensed psychiatrists, psychologists and advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing, and registered and/or certified master level counselors whose master's degree is in a field of study related to mental health services including but not limited to, social work, marriage and family therapy or mental health counseling, who are registered with the crime victims program are authorized to provide treatment in accordance with these rules to claimants.

Out-of-state providers must be licensed, registered and/or certified in accordance to the licensing requirements within the state in which they practice.  Copies of license, registration and/or certification must be provided when applying for approval to treat Washington state crime victims)) must qualify as an approved provider and register with the crime victims compensation program before they are authorized to provide treatment and receive payment in accordance with these rules.

(2) The following providers who are permanently licensed, registered or certified in Washington are eligible to register with this program:

(a) Psychiatrists;

(b) Psychologists;

(c) Advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing;

(d) Ph.Ds not licensed as psychologists and master level counselors whose master’s degree is in a field of study related to mental health services including, but not limited to, social work, marriage and family therapy or mental health counseling.

(3) Out-of-state providers must be currently licensed, registered and/or certified within the state in which they practice. Washington requires mental health counselors to have a masters degree to treat Washington crime victim clients.

EXCEPTION:

In areas where the department has determined licensed, registered and/or certified providers are not available, the department may consider registration exceptions on an individual ((case)) basis.

(((3) The department has a duty to supervise provision of proper and necessary mental health care that is delivered promptly, efficiently, and economically.  The department may deny, revoke, suspend, limit, or impose conditions on a mental health care provider's authorization to treat victims under the Crime Victims Act.  Reasons for imposing any of the above restrictions include, but are not limited to the following:

(a) Negligence or incompetence which results in injury to a claimant or which creates an unreasonable risk that a claimant may be harmed.

(b) The illegal possession, use, prescription for use, or distribution of controlled substances, legend drugs, or addictive, habituating, or dependency-inducing substances in any way other than for therapeutic purposes.

(c) Any temporary or permanent probation, suspension, revocation, or other relevant type of limitation of a provider's license, certification or registration to practice by any court, board, or administrative agency.

(d) The commission of any act involving moral turpitude, dishonesty, or corruption relating to the practice of the provider's profession.  The act need not constitute a crime.  If a conviction or finding of such an act is reached by a court or other tribunal pursuant to plea, hearing, or trial, a certified copy of the conviction or finding is conclusive evidence of the violation.

(e) Failure to comply with the department's orders, rules, or policies.

(f) Failure, neglect, or refusal to:

(i) Submit copies of license, certification and/or registration and degree to the department.

(ii) Maintain and provide records requested by the department pursuant to a health care services review or an audit.

(iii) Submit complete, adequate, and detailed reports or additional reports requested or required by the department regarding the treatment and condition of a claimant.

(g) The submission of, or collusion in the submission of, false or misleading reports or bills to any government agency.

(h) Billing a claimant for:

(i) Treatment of a condition for which the department has accepted responsibility; or

(ii) Any amount more than the amount paid by the department under the maximum allowable fee set forth in these rules and any other charge with the exception of "no show" appointment charges. The department has no provision to pay charges for missed appointments, except for independent assessments arranged by the department.  Claimants may be billed directly for missed or "no show" appointments.

(i) Repeated failure to recognize emotional and social factors impeding recovery of a claimant who is being treated under the Crime Victims Act.

(j) Repeated unreasonable refusal to comply with the recommendations of board certified or qualified consultants who have examined or reviewed a claim for the department.

(k) Repeated use of:

(i) Treatment of controversial or experimental nature;

(ii) Contraindicated or hazardous treatment; or

(iii) Treatment past stabilization of the condition or after maximum mental health improvement has been obtained.

(l) Declaration of mental incompetency by a court or other tribunal.

(m) Failure to comply with the applicable code of professional conduct or ethics.

(n) Failure to inform the department of any disciplinary action issued by order or formal letter taken against the provider's license, certification or registration to practice.

(o) The finding of any peer group review body of reason to take action against the provider's practice privileges.

(p) Misrepresentation or omission of any material information in the application for authorization to treat claimants.

(q) Repeated billing of the department for services that are available to claimants from public or private insurance sources. The crime victims compensation program is a secondary insurer.  Providers should bill the department only after all benefits available to the claimant from public or private insurance are exhausted.

(4) If the department finds reason to take corrective action, the department may also order one or more of the following:

(a) Recoupment of payments made to the provider, including interest; at the rate of one percent per month or portion of a month beginning on the thirty-first day after payment was made.

(b) Denial or reduction of payment;

(c) Placement of the provider on a prepayment review status requiring the submission of supporting documents prior to payment;

(d) Requirement to satisfactorily complete education courses and/or programs; and

(e) Imposition of other appropriate restrictions or conditions on the provider to include revocation of the privilege to be reimbursed for treating victims under the Crime Victims Act.

(5) The department shall forward a copy of any corrective action taken against a provider to the applicable disciplinary authority.

(6) Appeal and protest rights: A provider may file a written protest to any department order, decision, or award.  An appeal or protest to an order or decision demanding repayment of sums must be submitted to the department or the board of industrial insurance appeals within twenty days from receipt of the order or decision.  An appeal or protest to an order or decision regarding other issues, e.g., ongoing treatment or provider eligibility, must be filed within sixty days from receipt of the order or decision.  Appeal and protest rights are governed under RCW 51.52 and RCW 7.68.110.))

[Statutory Authority: RCW 7.68.030, RCW 51.04.020(1) and RCW 51.04.030.  95-15-004, § 296-31-030, filed 7/5/95, effective 8/5/95.  Statutory Authority: RCW 43.22.050.  92-23-033, § 296-31-030, filed 11/13/92, effective 12/14/92.]

You must send us:

(1) A completed provider application and Form W-9;

(2) A legible copy of your license, certification and/or registration;

(3) Ph.Ds not licensed as psychologists and master level counselors must provide a legible copy of their degree.

[]

The department has a duty to supervise the provisions of proper and necessary mental health care that is delivered promptly, efficiently and economically. We may deny, revoke, suspend or impose conditions on your authorization to treat crime victim claimants for reasons that include, but are not limited to:

(1) Incompetence or negligence that results in injury to a client or that exposes the client to harm.

(2) The possession, use, prescription for use, or distribution of controlled substances, legend drugs, or addictive, habituating or dependency-inducing substances except for therapeutic purposes.

(3) Limits placed on your license, certification and/or registration by any court, board or administrative agency. The limits may be temporary or permanent and may involve probation, suspension or revocation.

(4) The commission of any act involving moral turpitude, dishonesty, or corruption that relates to the practice of your profession. The act does not need to be a crime. If a court or other tribunal issues a conviction or finding regarding the act, a certified copy of the conviction or finding is conclusive evidence of the violation.

(5) Failure to comply with our rules, orders or policies.

(6) Failure, neglect or refusal to:

(a) Provide us with copies of your license, certification and/or registration and degree;

(b) Provide records requested by the department pursuant to a health care service review or an audit;

(c) Provide us with complete and timely reports that we require, or additional reports or records that we request.

(7) The submission or collusion in the submission of false or misleading reports or bills to any government agency.

(8) Billing a claimant for:

(a) Treatment of a condition for which the department has accepted responsibility; or

(b) The difference between the amount paid by the department and/or public or private insurance under the maximum allowable fee set forth in these rules and any other charge.

(9) Repeated failure to notify the department immediately and prior to burial in any death, where cause of death is not definitely known and possibly related to a crime victim injury.

(10) Repeated failure to recognize emotional and social factors that impede a client’s recovery.

(11) Repeated unreasonable refusal to comply with the recommendations of a board certified or qualified specialist who examines or reviews a claim for us.

(12) Repeated use of treatment that is:

(a) Controversial or experimental;

(b) Contraindicated or hazardous;

(c) Performed after the condition stabilizes; or

(d) Performed after maximum mental health improvement is reached.

(13) Mental incompetence declared by a court or other tribunal.

(14) Failure to comply with the applicable code of professional conduct or ethics.

(15) Failure to inform us of disciplinary action against your license, certification or registration to practice, issued by order or formal letter.

(16) The finding of reason(s) to take action against your privileges to practice by any peer group review body.

(17) Misrepresentation or omission of any material information in your application for authorization to treat crime victims.

(18) Repeated billing of the department for services that are available to clients from public or private insurance sources. You must bill us only after all public or private insurance benefits are exhausted.

[]

(1) If the department finds reason to take corrective action, we may also order one or more of the following:

(a) Recoup our payments to you with interest.

(b) Deny or reduce payment.

(c) Assessment of penalties for each action that falls within the scope of WAC 296-31-045 (1) through (18).

(d) Place you on a prepayment review status that requires you to submit supporting documents prior to payment.

(e) Require you to satisfactorily complete education courses and/or programs.

(f) Impose other appropriate restrictions or conditions, including revoking your privilege to be reimbursed for treating clients under the Crime Victims Act.

(2) Cases involving questions of ethics or quality of care will be referred to the department of health.

(3) We will forward a copy of any corrective action taken against you to the applicable disciplinary authority.

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(1) When you receive a payment to which you are not entitled, you must repay the excess payment, plus accrued interest, without regard to whether the excess payment occurred due to your error or department error or oversight.

EXCEPTION:

If you accept in good faith a determination by the department that a crime victim client is eligible for benefits under the Crime Victims Act and we later determine the client was ineligible for services, interest will not begin to accrue until notification is received by you that the client was ineligible.

(2) Interest will accrue on excess payments at the rate of one percent per month or portion of a month beginning on the thirty-first day after payment was made. When partial payment of an excess payment is made, interest accrues on the remaining balance.

(3) The department has the option of requesting you to remit the amount of the excess payment and accrued interest or offsetting excess payments and accrued interest against future payments due to you.

[]

The penalty provisions for physicians contained in RCW 51.48 are the same for mental health providers under these rules.

[]

If you or the client do not agree with our order, decision or award a written protest may be sent to the crime victims compensation program or appeal to the board of industrial insurance appeals. A protest or appeal to our order or decision requiring repayment by a provider must be received within twenty days from receipt of the order or decision. A protest or appeal regarding other issues must be received within ninety days of receipt of the order or decision.

Note:

Protest and appeal rights are governed under RCW 51.52 and RCW 7.68.110.

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(((1) The filing of a crime victims compensation claim, or the rendering of treatment to a victim who comes under the department's jurisdiction constitutes acceptance of the department's crime victims compensation mental health rules and mental health fees and compliance with its rules and fees.  In accordance with RCW 7.68.060(1) of the Crime Victims Act, when a mental health provider renders treatment to a victim entitled to benefits under the law, it shall be the duty of the mental health provider to inform the victim of his or her rights under this title and to lend all necessary assistance in making the application for compensation and such proof of other matters as required by the rules of the department without charge to the victim; a victim shall not be billed for treatment rendered for his or her accepted condition.  The department may be contacted to obtain brochures and copies of the act.

When there is questionable eligibility, (e.g., service is not usually allowed for crime victims when a investigation or claim determination is pending), the provider may require the claimant to pay for the treatment rendered.  In cases of questionable eligibility where the provider has billed the claimant or other insurance, and the claim is subsequently allowed, the provider shall refund the claimant in full within thirty days of notification of allowance of claim and bill the department for services rendered at usual and customary charges.  Cases in which there is a question of ethics or quality of care will be referred to the department of health.

(2) The department must be notified immediately when an unrelated condition is being treated concurrently with an accepted condition.

(3) Penalties.  The reporting requirements and penalty provision for physicians contained in RCW 51.36.060 and 51.48.060 shall be the same for physicians under these rules pursuant to RCW 7.68.100.

(4) Conditions preexisting the accepted condition are not the responsibility of the department.  When an unrelated condition is being treated concurrently with the accepted condition, the attending practitioner must notify the department immediately and submit the following:

(a) Diagnosis and/or nature of unrelated condition.

(b) Treatment being rendered.

(c) The effect, if any, on accepted condition.

Temporary treatment of an unrelated condition may be allowed, upon prior approval by the department, provided these conditions directly retard recovery of the accepted condition.  The department will not approve or pay for treatment for a known preexisting unrelated condition for which the claimant was receiving treatment prior to his or her crime victims claim, which is not retarding recovery from his or her accepted condition.

A thorough explanation of how the unrelated condition is affecting the accepted condition must be included with the request for authorization.

The department will not pay for treatment of an unrelated condition when it no longer exerts any influence upon the accepted condition.  When treatment of an unrelated condition is being rendered, reports must be submitted monthly outlining the effect of treatment on both the unrelated and the accepted conditions.

The department will not pay for treatment of unrelated conditions unless specifically authorized, including purchases of drugs or medicines.)) (1) When treating a crime victim who comes under our jurisdiction, you agree to accept and comply with the Crime Victims Compensation Program Mental Health Treatment Rules and Fees.

(2) You must inform the client they may be entitled to benefits under the Crime Victims Act and provide whatever assistance is necessary for the client to apply for benefits. There is no charge for these services.

(3) It is the responsibility of the client to notify the provider if they believe their condition is related to a criminal act. If you discover a condition that you believe is crime related, you must notify the client. It is your responsibility to determine if you are the first treating provider.

(4) If you are the first treating provider, you must:

(a) Provide crisis intervention as necessary;

(b) Provide instructions or help the client complete their portion of the application for benefits; and

(c) Continue necessary treatment according to our mental health rules if the client remains in your care.

(5) If you are not the first treating provider, you should ask the client if an application for benefits has been filed for the condition.

(a) If an application for benefits has been filed, and you and the client agree that a change of provider is desirable, the department should be notified of the transfer according to WAC 296-31-068.

(b) If an application for benefits has not been filed:

(i) Provide instructions or help the client complete their portion of the application for benefits; and

(ii) Include the name and address of the original provider, if known.

Note:

Providers must determine if the client has public or private insurance benefits available. If there is, the provider should make sure they would be able to continue treating under the client's primary insurance. Crime victims compensation is secondary to other benefits according to RCW 7.68.130.

(6) You must notify us and the client of the date they are released to regular work. Time-loss compensation terminates on the release date. We may allow further treatment if:

(a) You request it;

(b) Treatment is needed; and

(c) The accepted condition is not fixed and stable.

(7) You must notify us if permanent functional impairment or loss (permanent partial disability) is indicated after maximum recovery of the accepted condition is achieved. We will arrange to have impairments rated according to WAC 296-20-200 et al.

(8) A client must not be billed for treatment, except under the following condition:

A provider may require the client to pay for treatment if the client's eligibility is in question (e.g., when an investigation or claim determination is pending). If the claim is subsequently allowed, the provider must refund the client in full and bill us at their usual and customary fees if such rates are in excess of the public and private insurance entitlements.

(9) You must not bill a client for missed or no show appointments. No fee is payable by the department for missed appointments unless the appointment is for an examination arranged by the department.

[Statutory Authority: RCW 7.68.030, RCW 51.04.020(1) and RCW 51.04.030.  95-15-004, § 296-31-070, filed 7/5/95, effective 8/5/95.  Statutory Authority: RCW 43.22.050.  92-23-033, § 296-31-070, filed 11/13/92, effective 12/14/92.]

(1) You must immediately notify us when you are treating an unrelated condition concurrently with an accepted condition and provide us with the following information:

(a) Diagnosis and/or nature of unrelated condition;

(b) Treatment being provided; and

(c) The effect, if any, on the accepted condition.

(2) Temporary treatment of an unrelated condition may be allowed and payment for service authorized if:

(a) We approve your request for authorization prior to treatment;

(b) You give us a thorough explanation of how the unrelated condition is affecting the accepted condition;

(c) Treatment of the unrelated condition is retarding recovery of the accepted condition; and

(d) We receive monthly reports from you, outlining treatment and its effect on both the unrelated and accepted conditions.

(3) We will not approve or pay for treatment of:

(a) An unrelated condition that has no influence or no longer influences the existing condition.

(b) A preexisting unrelated condition that was treated prior to acceptance of the crime victim's claim, unless it is retarding recovery of the accepted condition.

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     The following sections of the Washington Administrative Code are repealed:

WAC 296-31-050	Initial treatment and application for benefits.
WAC 296-31-090	Mental health fees.