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PDFWAC 296-15-425

Communicating to injured workers during the course of the claim.

(1) How does a self-insurer communicate claims administration actions to workers?
The self-insurer must communicate in writing using a department-developed template to inform workers of actions involving delivery of benefits.
(2) What is the purpose of the department-developed template?
To provide timely and accurate delivery of benefits and prompt resolution of disputes during the course of a claim (between the allowance and closure of a claim); to promote efficient claims processing that is protective of workers and effective for employers by improving communications to workers, clarifying requirements and providing certainty of claims administration for self-insurers, and streamlining regulatory oversight by the department.
(3) When must a department-developed template be completed and sent to the worker?
Within five days of a claims administrator taking action on a claim involving:
(a) Calculation of the worker's monthly wage that forms the basis for time-loss compensation at time of payment;1
(b) Starting*, stopping, or denying time-loss or loss of earning power compensation;
(c) Acceptance or denial of a condition contended under the claim;
(d) Authorization or denial of treatment requested by a medical provider with specified diagnosis and procedure codes for treatment requiring authorization under WAC 296-20-03001; or
(e) Assessment of an underpayment or overpayment of benefits (from date of knowledge).
*When starting time-loss compensation the self-insurer must send a copy of the department-developed template and SIF-2 to the department.
(4) What is a department-developed template?
A department-developed template is used by the self-insurer to inform a worker of administrative actions on the claim involving delivery of benefits. The template:
(a) Informs the worker of the action being taken, and that if the worker disputes the action the worker should within sixty days write and ask the department to intervene to adjudicate the dispute.
(b) Upon receipt of a dispute, the department will intervene to adjudicate the matter and issue an order in accordance with RCW 51.52.050.
(c) If no dispute is received, then the department will not issue an order, and when the condition of the injured worker has become fixed, the self-insurer may close the claim in accordance with RCW 51.32.055 and WAC 296-15-450. If an overpayment remains unpaid at the time of closure, then upon request, the department will issue an overpayment order in accordance with RCW 51.32.240.
1When communicating the worker's monthly wage, the department-developed template will serve as a cover letter to the SIF-5A, the time-loss calculation rate notice under WAC 296-15-420.
[Statutory Authority: RCW 51.04.020. WSR 19-01-095, ยง 296-15-425, filed 12/18/18, effective 7/1/19.]
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