WSR 13-09-023

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed April 9, 2013, 9:42 a.m. , effective May 10, 2013 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: SSB 5801 (chapter 6, Laws of 2011), as it amends RCW 51.36.010, directs the department of labor and industries (L&I) to establish a statewide health care provider network to treat injured and ill workers and to expand the Centers for Occupational Health and Education (COHEs) in the workers' compensation system. Rules are necessary to implement these changes.

Self-insurers are included within the network provisions in SSB 5801.

An amendment to WAC 296-15-330 is adopted to ensure that L&I rules for self-insurers related to medical care are consistent with and include reference to the statewide health care provider network established in SSB 5801.

This rule making includes requirements that self-insurers make certain their workers receive the information necessary to access care within the health care provider network.

Citation of Existing Rules Affected by this Order: Amending WAC 296-15-330.

Statutory Authority for Adoption: RCW 51.36.010.

Other Authority: RCW 51.04.020 and 51.04.030.

Adopted under notice filed as WSR 13-03-126 on January 22, 2013.

A final cost-benefit analysis is available by contacting Leah Hole-Curry, L&I, P.O. Box 44321, Olympia, WA 98504-4321, phone (360) 902-4996, fax (360) 902-6315, e-mail Leah.Hole-Curry@Lni.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: April 9, 2013.

Joel Sacks

Director

OTS-4968.2


AMENDATORY SECTION(Amending WSR 06-06-066, filed 2/28/06, effective 4/1/06)

WAC 296-15-330   Authorization of medical care.   What are the requirements for authorization of medical care? Every self-insurer must:

(1) Authorize treatment and pay bills in accordance with Title 51 RCW and the medical aid rules and fee schedules of the state of Washington.

(2) Provide a written explanation of benefits (EOB) to the provider, with a copy to the worker if requested, for each bill adjustment. A written explanation is not required if the adjustment was made solely to conform to the maximum allowable fees as set by the department.

(3) Establish procedures to ensure prompt responses to inquiries regarding authorization decisions and bill adjustments.

(4) Comply with the requirements of the health care provider network. This includes:

(a) Utilizing only those providers approved for the provider network, except when the provider specialty or geographic location is not yet covered by the network;

(b) Providing information to workers about the requirement for providers to be enrolled in the network in order to treat injured workers and information on how a worker can find network providers. This information must be included in publications used by self-insurers to comply with WAC 296-15-400 (2)(a);

(c) Ensuring, when applicable, that only network providers are paid for care after the initial office or emergency room visit; and

(d) Promptly assisting workers who are being treated by a nonnetwork provider to transfer their care to a network provider of their choice; including, at a minimum, notification to the worker within forty-five days of receipt of the first bill from a nonnetwork provider that the provider will not be paid for treatment beyond the initial visit on the claim and information about how to find network providers.

[Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. 06-06-066, 296-15-330, filed 2/28/06, effective 4/1/06.]