General information. (1) The following
rules are promulgated pursuant to RCW 51.04.020 and 51.04.030.
The department or self-insurer may purchase necessary
physician and other provider services according to the fee
schedules. The fee schedules shall be established in
consultation with interested persons and updated at times
determined by the department in consultation with those
interested persons. Prior to the establishment or amendment
of the fee schedules, the department will give at least thirty
calendar days notice by mail to interested persons who have
made timely request for advance notice of the establishment or
amendment of the fee schedules. To request advance notice of
the establishment or amendment of the fee schedules,
interested persons must contact the department at the
Department of Labor and Industries
Health Services Analysis
Interested Person's Mailing List for the Fee Schedules
P.O. Box 44322
Olympia, WA 98504-4322
As an alternative, interested persons may subscribe to
the LI medical provider news listserv. To subscribe, go to
the department's web site at www.lni.wa.gov and click on the
link "Provider billing payment." Look for the icon that
says "Get E-mail Updates" and click on it.
The department or self-insurer will require the current
version of the federal Health Care Common Procedure Coding
System (HCPCS) Level I (or CPT) and II codes on January 1st,
of each new year. CPT refers to the American Medical
Association's Physicians' Current Procedural Terminology
The adoption of these codes on an annual basis is
designed to reduce the administrative burden on providers and
lead to more accurate reporting of services. However, the
inclusion of a service, product or supply within these new
codes does not necessarily imply coverage, reimbursement or
endorsement, by the department or self-insurer. The
department will make coverage and reimbursement decisions for
these new codes on an individual basis.
If there are any services, procedures or narrative text
contained in the new HCPCS Level I and II codes that conflict
with the medical aid rules or fee schedules, the department's
rules and policies take precedence.
Copies of the HCPCS Level I and II codes are available
for public inspection. These documents are available in each
of the department's service locations.
Copies of the HCPCS Level II codes may be purchased from:
The Superintendent of Documents
United States Government Printing Office
Washington, DC 20402
Copies of the Level I (or CPT) codes may be purchased
The American Medical Association
Chicago, Illinois 60601
In addition to the sources listed above, both the Level I
and II codes may be purchased from a variety of private
(2) The fee schedules are intended to cover all services
for accepted industrial insurance claims. All fees listed are
the maximum fees allowable. Practitioners shall bill their
usual and customary fee for services. If a usual and
customary fee for any particular service is lower to the
general public than listed in the fee schedules, the
practitioner shall bill the department or self-insurer at the
lower rate. The department or self-insurer will pay the
lesser of the billed charge or the fee schedules' maximum
(3) The rules contained in the introductory section
pertain to all practitioners regardless of specialty area or
limitation of practice. Additional rules pertaining to
specialty areas will be found in the appropriate section of
the medical aid rules.
(4) The methodology for making conversion factor cost of
living adjustments is listed in WAC 296-20-132. The
conversion factors are listed in WAC 296-20-135.
(5) L&I or self-insurers will not pay for a missed
appointment unless the appointment is for an examination
arranged by the department or self-insurer.
(6) Other than missed appointments for examinations
arranged by the department or self-insurer, a provider may
bill an injured worker for a missed appointment if:
(a) The provider has a missed appointment policy that
applies to all patients without regard as to which insurer or
entitlement program may be responsible for payment; and
(b) The provider routinely notifies all patients of the
missed appointment policy.
The implementation and enforcement of the policy is a
matter between the provider and the injured worker. L&I is
not responsible for the implementation and/or enforcement of
the provider's policy.
(7) When a claim has been accepted by the department or
self-insurer, no provider or his/her representative may bill
the worker for the difference between the allowable fee and
the usual and customary charge. Except for missed appointment
fees under subsection (6) of this section, the worker may not
be charged a fee, either for interest or completion of forms,
related to services for the industrial injury or condition.
(8) Practitioners must maintain documentation in claimant
medical or health care service records adequate to verify the
level, type, and extent of services provided to claimants. A
health care practitioner's bill for services, appointment
book, accounting records, or other similar methodology do not
qualify as appropriate documentation for services rendered. Refer to chapter 296-20 WAC and department policy for
(9) Except as provided in WAC 296-20-055 (Limitation of
treatment and temporary treatment of unrelated conditions when
retarding recovery), practitioners shall bill, and the
department or self-insurer shall pay, only for proper and
necessary medical care required for the diagnosis and curative
or rehabilitative treatment of the accepted condition.
(10) When a worker is being treated concurrently for an
unrelated condition the fee allowable for the service(s)
rendered must be shared proportionally between the payors.
(11) Correspondence: Correspondence pertaining to state
fund and department of energy claims should be sent to:
Department of Labor and Industries, Claims Administration,
P.O. Box 44291, Olympia, Washington 98504-4291.
Accident reports should be sent to: Department of Labor
and Industries, P.O. Box 44299, Olympia, Washington
Send all provider bills and adjustments to: Department
of Labor and Industries, P.O. Box 44269, Olympia, Washington
State fund claims have six digit numbers or a letter and
five digits preceded by a letter other than "S," "T," or "W."
All correspondence and billings pertaining to crime
victims claims should be sent to Crime Victims Division,
Department of Labor and Industries, P.O. Box 44520, Olympia,
Crime victim claims have six digit numbers preceded by a
"V" or five digit numbers preceded by "VA," "VB," "VC," "VH,"
"VJ," or "VK."
All correspondence and billings pertaining to
self-insured claims should be sent directly to the employer or
the service representative as the case may be.
Self-insured claims are six digit numbers or a letter and
five digits preceded by an "S," "T," or "W."
Communications to the department or self-insurer must
show the patient's full name and claim number. If the claim
number is unavailable, providers should contact the department
or self-insurer for the number, indicating the patient's name,
Social Security number, the date and the nature of the injury,
and the employer's name. A communication should refer to one
claim only. Correspondence must be legible and reproducible,
as department records are microfilmed. Correspondence
regarding specific claim matters should be sent directly to
the department in Olympia or self-insurer in order to avoid
rehandling by the service location.
(12) The department's various local service locations
should be utilized by providers to obtain information,
supplies, or assistance in dealing with matters pertaining to
[Statutory Authority: RCW 51.04.020. 12-05-098, §
296-20-010, filed 2/21/12, effective 3/23/12. Statutory
Authority: RCW 51.04.020, 51.36.080, 7.68.030, 7.68.080. 07-08-088, § 296-20-010, filed 4/3/07, effective 5/23/07. Statutory Authority: RCW 51.04.020. 05-09-063, § 296-20-010,
filed 4/19/05, effective 7/1/05; 03-21-069, § 296-20-010,
filed 10/14/03, effective 12/1/03. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 96-10-086, § 296-20-010, filed
5/1/96, effective 7/1/96. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 94-14-044, § 296-20-010,
filed 6/29/94, effective 7/30/94; 93-16-072, § 296-20-010,
filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 92-24-066, § 296-20-010, filed
12/1/92, effective 1/1/93; 90-04-057, § 296-20-010, filed
2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), §
296-20-010, filed 11/30/87, effective 1/1/88; 86-20-074 (Order
86-36), § 296-20-010, filed 10/1/86, effective 11/1/86;
86-06-032 (Order 86-19), § 296-20-010, filed 2/28/86,
effective 4/1/86; 83-16-066 (Order 83-23), § 296-20-010, filed
8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030,
and 51.16.120(3). 81-24-041 (Order 81-28), § 296-20-010,
filed 11/30/81, effective 1/1/82; 81-01-100 (Order 80-29), §
296-20-010, filed 12/23/80, effective 3/1/81; Order 76-34, §
296-20-010, filed 11/24/76, effective 1/1/77; Order 75-39, §
296-20-010, filed 11/28/75, effective 1/1/76; Order 74-7, §
296-20-010, filed 1/30/74; Order 70-12, § 296-20-010, filed
12/1/70, effective 1/1/71; Order 68-7, § 296-20-010, filed
11/27/68, effective 1/1/69.]