LABOR AND INDUSTRIES
Effective Date of Rule: Thirty-one days after filing.
Purpose: This rule making will update four rules under chapter 296-30 WAC and will add one rule to be consistent with SSB 5691 (chapter 346, Laws of 2011). The updates include removal of references to Title 51 RCW, addition or clarification of some definitions, an explanation of new medical cap, fee schedule changes, and fee schedule change notification methods.
Citation of Existing Rules Affected by this Order: Amending WAC 296-30-010, 296-30-085, 296-30-090, and 296-30-100.
Statutory Authority for Adoption: Chapter 7.68 RCW.
Adopted under notice filed as WSR 11-17-108 on August 23, 2011.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 4, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 4, Repealed 0.
Date Adopted: October 31, 2011.
AMENDATORY SECTION(Amending WSR 01-22-105, filed 11/7/01, effective 12/8/01)
WAC 296-30-010 Definitions. The following definitions are used to administer the crime victims compensation program:
Acceptance, accepted condition: A determination by the department that the diagnosis of the claimant's medical or mental health condition is the result of the criminal act. The condition being accepted must be specified by one or more diagnostic codes from the current edition of the International Classification of Diseases, Clinically Modified (ICD-CM), or the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Authorization: Notification by a qualified
representative of the department that specific treatment,
services or equipment provided for the accepted condition is
allowable under the claim. Providers must ((
maintain records (( indicating the name of the qualified
representative)) naming the claim manager who authorizes
treatment, services or equipment.
Bodily injury: Any harmful or offensive touching, including severe emotional distress where no touching takes place when:
(1) The victim is not the object of the criminal act and:
(a) The distress is intentionally or recklessly inflicted by extreme or outrageous conduct;
(b) Caused the victim to have a reasonable apprehension of imminent bodily harm; and
(c) The victim is in the immediate vicinity at the time of the criminal act.
(2) The victim is the object of the criminal act and:
(a) The distress is intentionally or recklessly inflicted by extreme or outrageous conduct; and
(b) Caused the victim to have a reasonable apprehension of imminent bodily harm.
Claimant: A victim who submits an application for benefits, or on whose behalf an application is submitted.
Consultation: The services rendered by a ((
health care provider whose opinion or advice is requested by
the (( attending ())treating(( ) mental health)) provider, (( or
agency,)) or by the department, in the evaluation and/or
treatment of a claimant. Case management or case staffing
does not constitute a consultation.
Criminal act: An act defined in RCW 7.68.020, the occurrence of which can be verified by the department or which is reasonably credible. Physically impossible acts, highly improbable acts for which verification is not available, or unverified memories of acts occurring prior to the age of two will not be accepted as reasonably credible. In evaluating evidence to determine verification of claimed criminal acts, the department will give greater weight to the quality, than to the quantity, of evidence. Evidence that can be considered for verification of claimed criminal acts includes, but is not limited to, one or more of the following:
(1) Police or other investigation reports.
(2) Child protective services or other government agency reports.
(3) Diaries or journals kept by victims and others.
(4) Third party reports from school counselors, therapists and others.
(5) Current medical examinations.
(6) Medical or psychological forensic evaluations. In the absence of other adequate forensic evaluation reports, independent assessments per WAC 296-31-069 may be conducted when indicated.
(7) Legal and historical reports.
(8) Current and past medical and mental health records.
(9) Reports of interviews with the victim's family members, friends, acquaintances and others who may have knowledge of pertinent facts. When such interviews are necessary to determine eligibility, the victim will be given the choice of whether to allow the interviews to be conducted. The victim will also be given the understanding that eligibility may be denied if the interviews are not conducted. The department will act according to the victim's choice.
Crisis intervention: Therapy to alleviate the claimant's most pressing problems. The vital mental and safety functions of the claimant are stabilized by providing support, structure and, if necessary, restraint.
Disability awards for mental health conditions: Direct
monetary compensation that may be provided to an eligible
claimant who is either temporarily totally disabled,
permanently totally disabled, or permanently partially
disabled resulting from an accepted condition.))
Evidence-based and curative treatment: Treatment practices, interventions and services that are supported by empirically based research and shown to produce consistent and effective outcomes.
Family therapy: Therapy involving one or more members of the claimant's family, excluding the perpetrator, which centers on issues resulting from the claimant's sexual assault pursuant to WAC 296-30-080.
Group therapy: Therapy involving the claimant, and one or more clients who are not related to the claimant, which includes issues related to the claimant's condition and pertinent to other group members.
Immediate family members: Any claimant'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.
Individual therapy: Therapy provided on a one-to-one
basis between a ((
therapist)) provider and client.
Lost wage certification: Documentation from a treating provider based on objective medical evidence stating the claimant is not able to work based on the effects of the crime injury.
Mental health provider: Any person, firm, corporation, partnership, association, agency, institution, or other entity providing any kind of mental health services related to the treatment of a claimant. This includes, but is not limited to, hospitals, psychiatrists, psychologists, advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing, registered and/or licensed master level counselors, and other qualified service providers licensed, registered and/or certified with the department of health and registered with the crime victims compensation program. (Refer to WAC 296-31-030 for specific details.)
Permanent partial disability: Any anatomic or
functional loss after maximum recovery has been achieved. When the attending provider has reason to believe a permanent
functional loss exists, the department should be notified. Specified disabilities (amputation or loss of function of
extremities, loss of hearing or vision) are to be rated
utilizing a nationally recognized impairment rating guide. Unspecified disabilities (internal injuries, spinal injuries,
mental health, etc.) are to be rated utilizing the category
system detailed under WAC 296-20-200, et al. Under Washington
law disability awards are based solely on physical or mental
impairment due to the accepted injury or conditions without
consideration of economic factors. Maximum benefit levels are
established by statute.
Permanent total disability (pension): A condition permanently incapacitating a claimant from performing work at any gainful employment. Maximum benefit levels are established by statute.))
Payer of last resort: The crime victims compensation program pays after all other public or private insurance programs, up to our fee schedule.
Proper and necessary: ((
(1))) Proper and necessary
services for the diagnosis or rehabilitative treatment of an
accepted condition(( ;)):
(2))) (1) Reflective of accepted standards of good
practice within the scope of the provider's license,
certification, or registration;
(3))) (2) Not delivered primarily for the convenience
of the claimant, the claimant's attending provider, or another
(4))) (3) Curative or rehabilitative care that produces
long lasting changes which reduces the effects of the accepted
(5))) (4) Provided at the least cost and in the least
intensive setting of care consistent with the other provisions
of this definition; and
(6))) (5) Concluded once a claimant has reached a state
of maximum improvement. Maximum improvement occurs when no
fundamental or marked change in an accepted condition can be
expected with or without treatment. A claimant's condition
may have reached maximum improvement though it might be
expected to improve or deteriorate with the passage of time. Once a claimant's condition has reached maximum improvement,
treatment that results only in temporary changes is not proper
and necessary. Maximum improvement is equivalent to fixed and
Reasonable cooperation: The victim is able to talk to the police and give information to help in the investigation and prosecution of the alleged offender. There may be circumstances in which the victim is not able to fully cooperate. In these instances, consideration is given to the needs of the victim. The department may consider the following issues. The list is not inclusive:
(1) There is fear of retribution from the offender;
(2) There is a mental or physical condition which inhibits cooperation;
(3) The victim is dependent upon the offender for support;
(4) The victim is a minor.
Temporary partial disability (loss of earning power):
Partial time loss compensation may be paid when the claimant
can return to work on a limited basis, or return to a lesser
paying job is necessitated by the accepted condition. The
claimant must have a reduction in wages of at least five
percent before consideration of partial time loss can be made.
No partial time loss compensation can be paid after the
claimant's condition is stationary. All time loss
compensation must be certified by the attending provider based
on objective findings.
Temporary total disability (time loss compensation): Time loss compensation may be paid when the claimant is temporarily unable to return to reasonable continuous gainful employment as a direct result of an accepted condition. Maximum benefit levels are established by statute.))
Termination of treatment: Treatment is concluded when
treatment)) it is no longer (( required)) curative because
the accepted condition for which the claim was allowed has
become stable. The provider (( should)) shall submit a report
indicating the date the condition became stable to the
department. (( The claimant may require continued treatment
for conditions not related to the crime injury condition;
however, financial responsibility for such care must be the
The result of: The test used to define "the result of"
used in RCW ((
7.68.070(3))) 7.68.060 (2)(a) is two-pronged. First, it must be determined that cause in fact exists, and
second, it must then be determined that proximate cause
(1) Cause in fact exists if "but for" the acts of the victim the crime that produced the injury would not have occurred.
(2) Proximate cause exists if, once cause in fact is found, it is determined that the acts of the victim:
(a) Resulted in a foreseeable injury to the victim;
(b) Played a substantial role in the injury; and
(c) Were the direct cause of the injury.
Time loss certification: Documentation from a
physician, or mental health professional qualified to treat
under the Crime Victims Act, based upon objective findings
which are specific symptoms that an accepted condition of a
claimant either partially or totally incapacitates the
claimant from returning to work.))
Treating provider: A person licensed to practice one or more of the following professions: Medicine and surgery, osteopathic medicine and surgery, chiropractic naturopathic physician, podiatry, dentistry, optometry, advanced registered nurse practitioner (ARNP), mental health therapists, and certified medical physician assistants or osteopathic physician assistants. A treating provider actively treats an injured or ill claimant.
Unjustly enriched: It would not be fair or equitable justice to allow a person to obtain, or have control of, or access to benefits or compensation paid to a victim of crime.
[Statutory Authority: RCW 7.68.030. 01-22-105, § 296-30-010, filed 11/7/01, effective 12/8/01; 00-10-003, § 296-30-010, filed 4/20/00, effective 5/22/00. 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, § 296-30-010, filed 12/31/96, effective 1/31/97. Statutory Authority: Chapter 7.68 RCW. 94-02-015, § 296-30-010, filed 12/23/93, effective 1/24/94. Statutory Authority: RCW 7.68.030, 7.68.070 (12) and (16) and 51.04.030. 89-23-004, § 296-30-010, filed 11/3/89, effective 11/10/89. Statutory Authority: Chapter 7.68 RCW. 86-01-028 (Order 85-37), § 296-30-010, filed 12/11/85; 85-03-060 (Order 85-3), § 296-30-010, filed 1/15/85.]
(a) A completed provider application and Form W-9.
(b) A legible copy of your professional license, certification and/or registration.
(c) Ph.D.s 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
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. All copayments, deductibles or out-of-pocket
expenses not covered by primary insurance should be included
in your billings to the department.
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.
[Statutory Authority: RCW 7.68.030, 7.68.080, 7.68.130. 00-03-056, § 296-30-085, filed 1/14/00, effective 2/14/00.]
|EXCEPTION:||A provider may require the claimant to pay for treatment if the claimant's eligibility is pending. If benefits are authorized, and payable by the department, the provider must refund the claimant in full.|
|EXCEPTION:||If any of the percentage of the maximum allowable fees ((
[Statutory Authority: RCW 7.68.030. 05-16-096, § 296-30-090, filed 8/2/05, effective 9/2/05. Statutory Authority: RCW 7.68.030, 7.68.080, 7.68.130. 00-03-056, § 296-30-090, filed 1/14/00, effective 2/14/00.]
[Statutory Authority: RCW 7.68.030. 00-03-056, § 296-30-100, filed 1/14/00, effective 2/14/00.]