Date of Adoption: September 29, 1999.

Purpose: A task force was formed to develop guidelines for mental health treatment of crime victims. These amendments are made to implement the recommendations from the Mental Health Treatment Guidelines Task Force. Other sections of the rules effected have been rewritten for more clarity in connection with Executive Order 97-02 on regulatory improvement. New sections were added to separate out topics into separate rules.

Citation of Existing Rules Affected by this Order: See Statutory Authority below.

Statutory Authority for Adoption:

Amendments to:	Statutory authority:
WAC 296-31-010 Mental health treatment overview	RCW 7.68.030, 7.68.130, 51.04.030, 51.36.010
WAC 296-31-060 Reporting requirements	RCW 7.68.030, 51.04.030, 51.36.060
WAC 296-31-065 Ongoing treatment	RCW 7.68.030, 51.04.030
New sections:
WAC 296-31-012 What mental health treatment and services are not authorized?	RCW 7.68.030, 51.04.030, 51.36.010
WAC 296-31-016 What treatment or services require authorization from the crime victims compensation program?	RCW 7.68.030, 51.04.030
WAC 296-31-067 When is concurrent treatment allowed?	RCW 7.68.030, 51.04.030
WAC 296-31-068 When can a client transfer providers?	RCW 7.68.030, 7.68.130, 51.36.010

Adopted under notice filed as WSR 99-15-100 on July 21, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 4, Amended 3, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 4, Amended 3, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 4, Amended 3, Repealed 0. Effective Date of Rule: November 1, 1999.

September 29, 1999

Gary Moore

Director

OTS-3034.2

AMENDATORY SECTION(Amending WSR 97-02-090, filed 12/31/96, effective 1/31/97)

WAC 296-31-010
((Mental health treatment overview.)) What mental health treatment and services are available?

(1) The crime victims compensation program provides payment for mental health treatment and services to victims of crime((, except for the provisions of WAC 296-30-025 (6)(b), secondary to treatment available from any other public or private insurance,)) who are eligible for compensation under ((the provisions of)) chapter 7.68 RCW, the Crime Victims' Act.  ((Eligible claimants are entitled to receive proper and necessary mental health treatment.))

EXCEPTION:

Benefits under the crime victims compensation program are secondary to services available from any other public or private insurance.

(2) Services and treatment are limited to ((those)) procedures ((which are proper and necessary, and at the least cost, consistent with accepted standards of mental health care which will enable the claimant to obtain maximum recovery and/or:

(3) In the case of a permanent partial disability, treatment or services are not to extend beyond the date when permanent partial impairment or disability compensation is awarded.  No treatment or services will be authorized beyond the point that the accepted condition is fixed and stable.

(4) In the case of a permanent total disability, treatment is not to extend beyond the date on which the claimant is placed upon a permanent pension roll except that in the sole discretion of the department continued treatment for conditions previously accepted by the department may be allowed when such treatment is deemed necessary to protect the claimant's life or to provide for the administration of therapeutic measures.  This includes payment of prescription medications necessary to alleviate continuing pain resulting from the accepted condition but does not include those controlled substances scheduled by the state board of pharmaceuticals as schedule I, II, III, IV substances under chapter 69.50 RCW.

(5) Mental health treatment requiring preauthorization:

Inpatient hospitalization;

Individual therapy exceeding one hour per week;

Group therapy exceeding one session per week;

Concurrent treatment;

Family therapy to family members of sexual assault victims beyond twelve sessions;

Therapy for survivors of victims of homicide beyond twelve sessions;

Electroconvulsive therapy;

Neuropsychological evaluation (testing);

Day treatment for seriously ill persons less than eighteen years of age;

Referrals to special programs.

Requests for authorization must be in writing and include a statement of:

(a) The condition(s) diagnosed;

(b) ICD-9-CM and/or DSM-III-R or DSM-IV codes;

(c) The relationship of the condition(s) diagnosed to the assault, if any;

(d) An outline of the proposed treatment program, its length and components, procedure codes, and expected prognosis.

(6) Rejected and closed claims.  Therapy for eligible survivors of victims of homicide can be provided on closed claims:

No payment will be made for treatment or medication on rejected claims or for services rendered after the date of closure of a claim.

When the department has denied responsibility for an alleged crime victim injury or condition, the only services which will be paid are those which were carried out at the specific request of the department and/or those assessment or diagnostic services which served as a basis for the adjudication decision.  Following the date of the order and notice of claim closure, the department will be responsible only for those services specifically requested or those assessments and/or diagnostic services necessary to complete and file a reopening application)) that are:

(a) Proper and necessary for the diagnoses of an accepted condition;

(b) Available at the least cost;

(c) Consistent with accepted standards of mental health care; and

(d) Will enable the client to reach maximum recovery.

[Statutory Authority: RCW 51.36.010, 7.68.030, 51.04.020 (1) and (4), 51.04.030, 7.68.080 and 7.68.120.  97-02-090, § 296-31-010, filed 12/31/96, effective 1/31/97.  Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030.  95-15-004, § 296-31-010, filed 7/5/95, effective 8/5/95.  Statutory Authority: RCW 43.22.050.  92-23-033, § 296-31-010, filed 11/13/92, effective 12/14/92.]

(1) The crime victims compensation program will not authorize services and treatment:

(a) Beyond the point that the accepted condition becomes fixed and stable (i.e., maintenance care);

(b) After the date a permanent partial disability award is made;

(c) After a client is placed on a permanent pension roll, except as allowed in RCW 51.36.010;

(d) After consultation and advice to the department, any treatment deemed to be dangerous or inappropriate; or

(e) When treatment is defined as unnecessary or prohibited in WAC 296-31-020.

(2) We will not pay for services or treatment, including medications:

(a) On rejected claims;

EXCEPTION:

We will pay for assessments or diagnostic services used as a basis for the department's decision.

(b) After the date a claim is closed.

EXCEPTION:

Therapy for eligible survivors of victims of homicide can be provided on closed claims.

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(1) The program must authorize the following mental health services and/or treatment:

(a) Treatment beyond thirty sessions for adults or forty sessions for children;

(b) Treatment beyond fifty sessions for adults or sixty sessions for children;

(c) Consultations beyond what are allowed in WAC 296-31-065;

(d) Inpatient hospitalization;

(e) Concurrent treatment with more than one provider;

(f) Electroconvulsive therapy;

(g) Neuropsychological evaluation (testing);

(h) Day treatment for seriously ill children under eighteen years old;

(i) Referrals for services or treatment not in our fee schedule (see WAC 296-31-040).

(2) Your request for authorization must be in writing and include:

(a) A statement of the condition(s) diagnosed;

(b) Current DSM or ICD codes;

(c) The relationship of the condition(s) diagnosed to the criminal act; and

(d) An outline of the proposed treatment program that includes its length, components, procedure codes and expected prognosis.

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((The department may require reports at any time as is necessary in order to determine initial or continued authorization of benefits or services.  However, the department requires the following reports at various stages of a claim in order to authorize mental health treatment or services, time loss compensation, and bill payments for innocent victims of crime:

(1) Initial report of injury: To establish a claim, an application for benefits must be completed and submitted to the department.  The provider may bill under code 1040M for the filing of the application.  In addition, the examination or assessment charge may be billed.  Reimbursement of these services will be paid if the claim is allowed by the department.  Billing for an extended or comprehensive visit of more than one hour may require submission of additional reports.

(2) Initial evaluation report: This report must be submitted by the provider no later than thirty days from the date of first treatment or the date the claim is allowed, whichever is later.  The report must include the preliminary diagnosis and symptoms, proposed treatment plan and treatment goals, including the treatment modality or modalities to be employed, and expected length of treatment.  It must also include a diagnosis of any preexisting conditions and their potential effect on the condition resulting from the assault.  Any change in the treatment plan must be addressed either in a modified treatment plan submitted to the department or in a ninety-day narrative report.  Absence of a response from the department to the proposed treatment plan or modification within fourteen days shall constitute authorization to proceed with the plan as long as the treatment plan does not contain measures requiring preauthorization per WAC 296-31-010(5).

(3) Office notes and follow-up visits: Legible copies of office or progress notes or other work products may be, as determined by the department, required documentation to substantiate all follow-up visits or treatment following the initial evaluation.  Office notes are not acceptable in lieu of requested narrative reports.

(4) Ninety-day narrative reports: When treatment is to continue beyond ninety days from the first date of treatment, submission of a narrative report is required every ninety days to substantiate the need for continued care.  A narrative report must contain the basic information outlined in these rules.  A narrative report should be billed under code 0100C and described as a ninety-day report.  Treatment in excess of ninety days may be authorized by the department only after receipt and review of the ninety-day narrative report.  Absence of a response from the department to a report shall constitute authorization for continued treatment.  When treatment beyond ninety days will not be authorized or is authorized with limits on frequency or provider type, notification will be sent by the department giving a thirty-day transition period.  In the case of a contested decision, a claimant or a provider may file a written protest to the department or appeal to the board of industrial insurance appeals.  Ninety-day progress reports must include current DSM III, DSM IV, and/or ICD-9-CM diagnosis(es), their relationship (if any) to the conditions sustained as the result of the criminal act, a summary of the progress made toward therapy goals or issue resolutions established in the initial evaluation, an estimate of the duration and frequency of further sessions and an updated prognosis for recovery.

(5) Hospital reports: When the claimant is hospitalized, it is the responsibility of the attending mental health provider to submit his or her reports to the hospital for submission with the hospital billing.  The attending mental health provider may bill for hospital visits without attaching copies of the reports.

(6) Consultation reports: To substantiate treatment of more than one hundred eighty days, a consultation with a consultant chosen by the attending mental health provider is required.  The department may require the claimant to be examined by the consultant as part of the consultation process with supervisory approval.  Although no prior authorization is required for such consultations, the consultant must meet crime victims compensation program's provider registration requirements and the department must be notified when such consultation is arranged.  The consultant is responsible for submitting a copy of the report, following guidelines developed by the department, within fifteen days from the date of the consultation.  Treatment may only be authorized to extend beyond one hundred eighty days in mental health cases after the department has received this report.  Absence of response, by the department upon receipt of the report shall constitute authorization for additional treatment.  When extended treatment will not be authorized or will be terminated, notification will be sent by the department giving a thirty-day transition period.   The department may request additional consultations and/or independent assessments as warranted by the individual case.

(7) Termination reports: When a mental health practitioner discontinues treatment of a claimant because the condition for which treatment was provided is fixed and stable or for any other reason, a termination report shall be completed and provided to the program within sixty days of the last visit.

(8) Reopening application: On claims closed over sixty 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.)) The crime victims compensation program requires the following reports from mental health providers:

(1) Initial response and assessment: Form I: This report is required if you are seeing the client for six sessions or less, and must contain:

(a) The client's initial description of the criminal act for which they have filed a crime victims compensation claim;

(b) The client's presenting symptoms/issues by your observations and the client's report;

(c) An estimate of time loss from work as a result of the crime injury, if any. Provide an estimate of when the individual will return to work, why they are unable to work, the extent of impairment and the prognosis for future occupational functioning; and

(d) What type of intervention(s) you provided.

EXCEPTION:

If you will be providing more than six sessions it is not necessary to complete Form I, instead complete Form II.

(2) Initial response and assessment: Form II: This report is required if more than six sessions are anticipated. Form II must be submitted no later than the sixth session, and must contain:

(a) The client's initial description of the criminal act for which they have filed a crime victims compensation claim;

(b) A summary of the essential features of the client's symptoms related to the criminal act, beliefs/attributions, vulnerabilities, defenses and/or resources that lead to your clinical impression (refer to current DSM and crime victims compensation program guidelines);

(c) Any preexisting or coexisting emotional/behavioral or health conditions relevant to the crime impact if present, and how they may have been exacerbated by the crime victimization;

(d) Specific diagnoses with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(e) Treatment plan based on diagnoses and related symptoms, to include:

(i) Specific treatment goals you and the client have set;

(ii) Treatment strategies to achieve the goals;

(iii) How you will measure progress toward the goals; and

(iv) Any auxiliary care that will be incorporated.

(f) A description of your assessment of the client's treatment prognosis, as well as any extenuating circumstances and/or barriers that might affect treatment progress; and

(g) An estimate of time loss from work as a result of the crime injury, if any. Provide an estimate of when the individual will return to work, why they are unable to work, the extent of impairment and the prognosis for future occupational functioning.

(3) Progress note: Form III: This report must be completed after session fifteen has been conducted, and must contain:

(a) Whether there has been substantial progress towards recovery for the crime related condition(s);

(b) If you expect treatment will be completed within thirty visits (for adults) or forty visits (for children); and

(c) What complicating or confounding issues are hindering recovery.

(4) Treatment report: Form IV: This report must be completed for authorization for treatment beyond thirty sessions for adults or forty sessions for children, and must contain:

(a) The diagnoses at treatment onset with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(b) The current diagnoses, if different now, with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year; and

(c) Proposed plan for treatment and number of sessions requested, and an explanation of:

(i) Substantial progress toward treatment goals;

(ii) Partial progress toward treatment goals; or

(iii) Little or no progress toward treatment goals.

(5) Treatment report: Form V: This report must be completed for authorization for treatment beyond fifty sessions for adults or sixty sessions for children, and must contain:

(a) The diagnoses at treatment onset with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(b) The current diagnoses, if different now, with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(c) Proposed plan for treatment and number of sessions requested, and an explanation of:

(i) Substantial progress toward treatment goals;

(ii) Partial progress toward treatment goals; or

(iii) Little or no progress toward treatment goals.

(6) Termination report: Form VI: If you discontinue treatment of a client for any reason, a termination report should be completed within sixty days of the client's last visit, and must contain:

(a) Date of last session;

(b) Diagnosis at the time client stopped treatment;

(c) Reason for termination (e.g., goals achieved, client terminated treatment, client relocated, referred to other services, etc.); and

(d) At this point in time do you believe there is any permanent loss in functioning as a result of the crime injury? If yes, describe symptoms based on diagnostic criteria for a DSM diagnosis.

(7) Reopening application: This application is required to reopen a claim that has been closed more than ninety days, to demonstrate a worsening of the client's condition and a need for treatment. We will reimburse you for filing the application, for an office visit, and diagnostic studies needed to complete the application. No other benefits will be paid until a decision is made on the reopening. If the claim is reopened, we will pay benefits for a maximum of sixty days prior to the date we received the reopening application.

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030.  95-15-004, § 296-31-060, filed 7/5/95, effective 8/5/95.  Statutory Authority: Chapter 7.68 RCW.  94-02-015, § 296-31-060, filed 12/23/93, effective 1/24/94.  Statutory Authority: RCW 43.22.050.  92-23-033, § 296-31-060, filed 11/13/92, effective 12/14/92.]

(((1) Cases that remain open more than one hundred eighty days: When the claimant requires treatment beyond one hundred eighty days, a consultation with another mental health provider who meets the department's provider registration requirements, is necessary to determine and/or establish the need for continued treatment and/or payment of time-loss compensation.  A detailed consultation report must be provided to the department.

Three levels of consultation are recognized: Limited, extensive and complex.  Detailed descriptions of each type of consultation are included under procedure codes 0108C, 0109C and 0110C in the publication entitled Crime Victims Compensation Mental Health Treatment Rules and Fees.

(2) Procedures and/or continued treatment requiring consultation: In the event of complication, controversy, or dispute over the treatment aspects of any claim, the department will not authorize continued treatment until the complication, controversy, or dispute has been resolved and the department has received notification of any findings and reviewed any recommendations.

(a) The department may consider claims as complicated, controversial or disputed when involving treatment or conditions as follows:

(i) All counseling or psychotherapy, pertaining to immediate family members, requiring treatment sessions of more than twelve visits.

(ii) All family therapy visits, not including the claimant, requiring more than twelve visits.

(iii) All conditions not related to the accepted condition involving emotional, psychiatric, or social problems which are likely to complicate recovery.

(iv) All therapeutic procedures of a controversial nature or type not in common use for the specific condition.

(v) Cases where there are complications or unfavorable circumstances such as age, preexisting conditions, or, because of occupational requirements, etc.

(vi) Elective nonemergent hospital admission.

(vii) Any other circumstance that the department may define.

(b) The department may resolve issues of claim complication, controversy, or dispute using consultants, independent assessments and/or requesting a review of policies or procedures by the department's mental health advisory committee.  The committee may recommend courses of action to resolve these issues to including, but not limited to, recommendation of an independent assessment.

(c) In cases presenting diagnostic or therapeutic problems difficult to resolve to the attending mental health provider (psychiatrist, psychologist and/or counselor), consultation with a specialist will be allowed without prior authorization.  The consultant must submit his or her findings and recommendations immediately to the attending provider and the department.  

(i) Whenever possible, the referring mental health provider should make his or her records available to the consultant to avoid unnecessary duplication.  Consultants may proceed with indicated and reasonable diagnostic studies as permitted within their scope of practice.

(ii) Consultations must be held within the local geographic area of the claimant's residence, if possible, and with a consultant not having a mutual proprietary or business interest with the attending mental health provider.  Exceptions to this requirement may be made only with department preauthorization.  The department does not prohibit the use of members of the same professional or social associations.

(iii) The mental health provider will not arrange a consultation if notification has been received that an independent assessment is being arranged by the department.  If a recent consultation has been completed and the attending mental health provider is notified that the department is arranging an assessment, the department must be advised immediately of the consultation.

(iv) The consultation fee will be paid only if a consultation report is complete and contains all psychological findings as well as all pertinent negative or normal findings.  The report must be received in the department within fifteen days from the date of the consultation.  No fee may be paid to the consultant, by the department, if the claimant misses/fails to attend the appointment.  However, the claimant may be billed directly.

(v) The consultant may not order, prescribe, or provide treatment without the consent of the claimant.  No transfer will be made to the consultant without the written request of the claimant.

(3) Concurrent treatment: In some cases, treatment by more than one provider may be allowed.  The department will consider authorization of concurrent treatment when the accepted condition requires specialty or multidisciplinary care.  (Individual and group counseling sessions provided by more than one provider is not concurrent treatment.) When requesting consideration of concurrent treatment, the attending mental health provider must provide the department with the following: The name, address, discipline, and specialty of all other providers requested to assist in the treatment of the claimant and an outline of their responsibility in the case and an estimate of the length of the period of concurrent care.  When concurrent care is allowed, the department will recognize one primary attending mental health provider, who will be responsible for directing the over-all treatment program; providing copies of all reports and other data received from the involved providers and, in time loss cases, providing the adequate certification evidence of the claimant's inability to work.  The department will approve concurrent care on an individual case basis.

(4) Transfer of attending provider: All transfers from one provider to another must be approved by the department.  Normally transfers will be allowed only after the claimant has been under the care of the attending mental health provider for sufficient time for the provider to: Complete the necessary diagnostic studies, establish an appropriate treatment regimen, and evaluate the efficacy of the therapeutic program.  Under RCW 51.36.010 claimants are entitled to free choice of attending provider subject to the limitations of RCW 7.68.130.  Except as provided under (a) through (g) of this subsection, no reasonable request for transfer will be denied.  The claimant must be advised when and why a transfer is denied.  The department reserves the right to require a claimant to select another provider for treatment, under the following conditions:

(a) When more conveniently located providers, qualified to provide the necessary treatment, are available.

(b) When the attending provider fails to cooperate in observance and compliance with the department rules.

(c) In time loss cases where reasonable progress towards return to work is not shown.

(d) Cases requiring specialized treatment, which the attending provider's authority is not qualified to render, or is outside the scope of the attending provider's authority to practice.

(e) Where the department finds a transfer of provider to be appropriate and has requested the claimant to transfer in accordance with this rule, the department may select a new attending provider if the claimant unreasonably refuses or delays in selecting another attending provider.

(f) In cases where the attending provider is not qualified to treat each of several accepted conditions.  This does not preclude concurrent care where indicated.

(g) No transfer will be approved to a consultant without the written request of the claimant.  Transfers will be authorized for the foregoing reasons or where the department in its discretion finds that a transfer is in the best interest of returning the claimant to a productive role in society.)) (1) There may be instances when the client's accepted mental health condition presents a diagnostic or therapeutic challenge. In such cases, you or the department may refer the client for a consultation or you may ask the department for an independent mental health examination.

(2) There are two levels of consultations that can be performed: Limited and extensive. Descriptions and procedure codes are included in the Crime Victims Compensation Program Mental Health Treatment Rules and Fees.

(3) The consultant will be required to submit a report to the department that contains the following elements:

(a) The reason(s) for the consultation referral; and

(b) Consultants related recommendations.

(4) Authorization from the department is required for:

(a) More than two consultations before the thirtieth session for adults or fortieth session for children; and

(b) More than one consultation between thirty and fifty sessions for adults or between forty and sixty sessions for children.

(5) You may not make a referral for a consultation if:

(a) An independent mental health examination has been scheduled;

(b) Claim reopening is pending; or

(c) The claim is closed.

Note: The consultant must meet provider registration requirements per WAC 296-31-030.

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030.  95-15-004, § 296-31-065, filed 7/5/95, effective 8/5/95.  Statutory Authority: Chapter 7.68 RCW.  94-02-015, § 296-31-065, filed 12/23/93, effective 1/24/94.  Statutory Authority: RCW 43.22.050.  92-23-033, § 296-31-065, filed 11/13/92, effective 12/14/92.]

(1) In some cases, treatment by more than one provider may be allowed by the crime victims compensation program. We may authorize concurrent treatment on an individual basis:

(a) If the accepted condition requires specialty or multidisciplinary care.

Note: Individual and group counseling sessions given by more than one provider is not concurrent treatment.

(b) If we receive and approve your written request that contains:

(i) The name, address, discipline, and specialty of each provider requested to assist in treating the client;

(ii) An outline of each provider's responsibility in the case; and

(iii) An estimated length for the period of concurrent treatment.

(2) If we approve concurrent treatment, we will recognize one primary attending mental health treatment provider. That provider will be responsible for:

(a) Directing the overall treatment program for the client;

(b) Providing us with copies of all reports received from involved providers; and

(c) In time loss cases, providing us with adequate evidence certifying the claimant's inability to work.

[]

(1) RCW 51.36.010 provides that clients are entitled to a free choice of attending providers, subject to the limits of RCW 7.68.130 and the requirements of the claimant's public or private insurance. The provider must meet registration requirements of WAC 296-31-030.

(2) The department must be notified if a client changes providers.

(3) We may require a client to select another provider for treatment under the following conditions:

(a) When a provider, qualified and available to provide treatment, is more conveniently located;

(b) When the attending provider fails to comply with our rules;

(c) Subject to the limits of RCW 7.68.130 outlined in subsection (1) of this section.

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