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PDFWAC 296-20-022

Payment of out-of-state providers.

(1) How will health care providers outside of Washington state be paid? All health care service providers, regardless of their geographic location, will be paid according to the fee schedule rules, rates, coverage and payment policies as published in the Washington state Medical Aid Rules and Fee Schedules and/or provider bulletins.
(2) Can an injured worker be charged for services? In all cases, the department's maximum allowed fees and payment levels are the maximum payable. If a provider's charge exceeds the maximum amount payable under the department's Medical Aid Rules and Fee Schedules, the provider must not charge the injured worker for the difference. A provider violating this provision may be held ineligible to treat injured workers as provided by department rules and may be subject to other applicable penalties.
When a provider treats an injured worker for condition(s) unrelated to the worker's accepted industrial injury or illness, the provider may bill the worker or other insurers for the unrelated services only.
(3) What services will be paid to providers outside of Washington? Only those diagnostic and treatment services authorized under the state of Washington medical aid rules, fee schedules, payment policies, or medical coverage decisions may be authorized or paid by the department or self-insurer. As determined by the department of labor and industries, the scope of practice of providers outside the state of Washington may be recognized for payment purposes. However, in all cases WAC 296-20-03002 (Treatment not authorized) shall apply. Specifically, services not authorized under Washington workers compensation rules, fee schedules, payment policies, or medical coverage decisions will not be paid, even if permitted under the workers compensation program in the provider's state or country of business. When in doubt, the provider should verify coverage of a service with the department or self-insurer.
[Statutory Authority: RCW 51.04.020, 51.04.030, 51.36.080. WSR 00-09-078, § 296-20-022, filed 4/18/00, effective 7/1/00. Statutory Authority: RCW 51.04.020(4) and 51.04.030. WSR 90-04-057, § 296-20-022, filed 2/2/90, effective 3/5/90; WSR 87-24-050 (Order 87-23), § 296-20-022, filed 11/30/87, effective 1/1/88; WSR 87-03-004 (Order 86-45), § 296-20-022, filed 1/8/87.]
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