WAC 296-20-12095   SIMP referral and prior authorization requirements.  (1) All SIMP services require:

     • Prior authorization by the claim manager; and

     • A referral from the worker's attending provider.

     An occupational nurse consultant, claim manager, or insurer assigned vocational counselor may recommend a SIMP for the worker, but this cannot substitute for a referral from the attending provider.

     (2) When the attending provider refers a worker to a chronic pain management program (i.e., a SIMP), the claim manager may authorize an evaluation if the worker has had unresolved chronic pain for longer than three months despite conservative care and has one or more of the following conditions:

     (a) Is unable to return to work due to the chronic pain;

     (b) Has returned to work but needs help with chronic pain management;

     (c) Has significant pain medication dependence, tolerance, abuse, or addiction;

     (d) Is a lumbar surgery candidate. It is recommended that lumbar surgery candidates be evaluated by a SIMP provider prior to requesting surgery.

     (3) Prior authorization for the evaluation phase occurs first and includes only one evaluation. Once authorized, the SIMP provider verifies the worker meets the requirements set forth in WAC 296-20-12090 and can fully participate in the program. If the worker:

     (a) Meets the requirements and the SIMP provider recommends the worker move on to the treatment phase, the SIMP provider must provide the insurer with a report and treatment plan as described under the evaluation phase.

     (b) Does not meet the requirements, the SIMP provider must provide the insurer with a report explaining what requirements are not met and the goals the worker must meet before he or she can return and participate in the program. If the worker is found to have important associated conditions during the evaluation phase that prevent him or her from participating in the treatment phase, the SIMP provider must either treat the worker or recommend to the worker's attending provider and the claim manager what type of treatment the worker needs.

     (4) The treatment phase must be prior authorized separately from the evaluation phase. Treatment phase authorization includes authorization for the follow up phase.

     (5) SIMP services are authorized on an individual basis. If there are extenuating circumstances that warrant additional treatment or a restart of the program, providers must submit this request along with supporting documentation to the claim manager.

     (6) If a lumbar surgery candidate previously participated in a SIMP as a lumbar surgery candidate but did not successfully complete treatment, one additional SIMP may be authorized only if:

     (a) The worker obtains an additional surgical recommendation noting clinical changes one year or more after the date first referred to a SIMP; or

     (b) The reason the worker did not participate fully or successfully complete a SIMP the first time was because of important associated conditions that are now fully resolved.

     (7) If a lumbar surgery candidate successfully completed a SIMP and did not have surgery, and in the future becomes a lumbar surgery candidate again, another SIMP may be authorized but is not required.

     (8) If a worker's treatment is interrupted due to significant family or life circumstances such as a death in the family, the claim manager may authorize resuming or restarting the SIMP if recommended by the SIMP provider.

     (9) If a SIMP provider plans to travel to the worker's community to deliver face-to-face services, mileage may be reimbursed, but only if it is authorized prior to travel. Lodging or meals (per diem expenses) are not reimbursable. Actual travel time is not included in the twenty-four-hour limit as stated in WAC 296-20-12080. When requesting prior authorization for mileage, the SIMP provider must explain the reason for the visit and how it will benefit the worker.



[Statutory Authority: RCW 70.14.120, 51.04.020, 51.04.030. 09-20-040, § 296-20-12095, filed 9/30/09, effective 11/1/09.]