Site Alert

Most of our online systems will be unavailable from 6 a.m. to 2 p.m. on Saturday, November 22, 2014, for scheduled system upgrades. We apologize for any inconvenience.

Answers to Common Questions


Expand or collapse all.

Law/Rule

  • Expand or collapse. What are the definitions for "initial visit" and "pre-initial visit?"

    Initial visit is defined in WAC 296-20-01002: "The first visit to a healthcare provider during which the Report of Industrial Injury or Occupational Disease is completed and the worker files a claim for workers' compensation." "Pre-initial visits" occur from the date of injury to the Initial Visit date.

    The impact of the MPN is that, if a provider is not currently a network provider, the provider can only be paid for initial visits.

  • Expand or collapse. Who is required to inform the non-network provider that they must either join the network, or transfer their patient's care to a network provider?

    The statute/rule does not specifically contain a requirement for the department or self-insurers to notify providers. Statute and rules require that providers be in the network to treat or be reimbursed for care beyond the initial visit. In 2012, the department sent multiple communications to all providers with active L&I accounts, informing them of these requirements.

    As a best practice to ensure full access to quality care and return the injured worker to work as quickly as possible, the Department and self-insurers should also seek to educate providers that may be unaware of the network requirements. All providers are encouraged to apply to the network and no enrollment limits are in place.

    Also note, that both the department and self-insurers have a general responsibility to inform and assist injured workers in meeting workers' compensation requirements, and must respond promptly to requests. Specific to network:
    "When the department terminates a provider from the network, the department or self-insurer shall assist an injured worker currently under the provider's care in identifying a new network provider or providers from whom the worker can select an attending or treating provider. In such a case, the department or self-insurer shall notify the injured worker that he or she must choose a new attending or treating provider." Reference: RCW 51.36.010 (9) (leg.wa.gov).


Enforcement

  • Expand or collapse. What happens if a self-insurer pays a non-network provider for ongoing care? Will L&I assess penalties?

    The department's enforcement of self-insurers' responsibility to assure that only network providers are paid for ongoing care after January 1, 2013 will, at first, be limited to education.

    The department does not plan to begin active regulatory enforcement of the MPN until later in the year, and will work with the self-insured community on our enforcement approach prior to starting any effort.

  • Expand or collapse. Is there a "grace period" for compliance on the use of network providers?

    The rules require that only network providers treat and get reimbursed for ongoing treatment for injured workers after January 1, 2013. The department is implementing the network on schedule and notifying all providers of their responsibility to enroll in the network.

    Separately, the department has a regulatory role with respect to self-insurers. The department's enforcement of self-insurers' responsibility to assure that only network providers are paid for ongoing care after January 1, 2013 will, at first, be limited to education. The department does not plan to begin active regulatory enforcement of the MPN until later in the year, and will work with the SIE community on our enforcement approach prior to starting any effort. We don't anticipate any penalty action prior to July 1, 2013.

    Initially, the department will not review self-insurers' bill payment activity for compliance with the MPN, nor will any penalties be assessed for failure to comply with MPN requirements. Instead, the department will use this time to answer questions and clarify requirements fully.

    We will continue our regular work in responding to provider billing disputes. If a dispute is directly related to a provider network requirement, it will be addressed on a fact-specific basis.

  • Expand or collapse. Will the Department require the National Provider Identifier (NPI) number on all bills?

    The department's bill payment systems currently require either the provider's NPI or L&I ID number on bills for medical services. The department will communicate with the provider community regarding the importance of including NPI, claim numbers, L&I provider numbers and other critical information on bills, in order to facilitate prompt and accurate payment. Self-insured employers retain their current responsibilities to determine when provider bills have sufficient information to be accurately processed. Self-insured employers are encouraged to educate providers on submitting bills with complete information.


Claims management

  • Expand or collapse. When making claims management decisions, can the medical opinion of an out of network provider be used?

    The workers' compensation reforms gave the department authority to set minimum standards for providers treating and being reimbursed for treatment of injured workers. Providing medical opinion and use of medical opinion in claim management decisions is not addressed in the MPN statute.

  • Expand or collapse. If an injured worker elects to continue treating with a non-network provider, can the non-network provider bill the worker?

    Title 51 is the sole remedy for workplace injuries and illnesses. Providers may not bill injured workers for claim related care, and employers may advise injured workers that they are not obligated to pay bills from non-network providers. Providers must apply and meet minimum network requirements to treat and bill L&I or the self-insurer for care of injured workers.

    L&I does not regulate providers, other than network enrollment or termination. The Department and self-insurers do have an obligation to inform and educate injured workers that their treatment must be through a network provider. L&I also informs providers that the law does not allow them to bill injured workers directly. On a case-by-case basis, we can also work with the provider to inform them about the law and, in exceptional situations, work with our legal counsel on communication to the provider.

    As a best practice to ensure full access to quality care and return the injured worker to work as quickly as possible, the Department and self-insurers should also seek to educate providers that may be unaware of the network requirements. All providers are encouraged to apply to the network and no enrollment limits are in place. Self-insurers may direct providers to Join the Medical Provider Network for more information.


Bill payment

Provider Types

  • Expand or collapse. What types of providers are required to be in the network?

    Providers are required to be in the network if they practice in Washington and they are one of the following types:

    Provider L&I Provider Type Code L&I Specialty Type Code
    Medical physicians and surgeons 20  
    Naturopathic physicians 92  
    Optometrists 28  
    Osteopathic physicians and surgeons 22  
    Podiatric physicians and surgeons 32  
    Advanced registered nurse practitioners 40 N1, N3, 36
    Chiropractic physicians 30  
    Dentists 27 9, 12, 19
    Physician assistants 21  
  • Expand or collapse. Are there any exceptions to the network requirement?

    Yes, providers in Washington are not subject to the health care network rule when they are employed by:

    • The Department of Corrections (DOC) and treat inmates with worker's comp injuries within the Washington state correctional system;
    • The armed forces and/or Veteran's Administration and treat injured workers in a federal military facility;
    • A recognized Washington State Indian Tribe and treat injured workers on federal reservation land.

Network Status Codes

Medical Records/Special Reports

Independent Medical Examiner (IME)

Ancillary Providers (PT/Lab/Massage/etc.), Prescriptions, and Durable Medical Equipment (DME)

Facility Charges

Urgent Care (place of service 20)

Emergency Room Services (place of service 23)

Inpatient Hospital: Professional Services (place of service 21/51)

Outpatient Hospital: Professional Services (place of service 22)

  • Expand or collapse. Should professional services for outpatient treatment be paid if provided by a non-network provider?

    No, unless the treatment provided is part of the initial visit (traumatic injuries).

    Note: Network status requirements apply in a hospital setting, except for the following provider types/specialties:

    Provider Type Provider Type Code Specialty Specialty Code
    MD 20
    Anesthesiology 05
    Pathology 22
    ER Physician 47
    Radiology 30
    DO 22
    Anesthesiology 05
    Pathology 22
    ER Physician 47
    Radiology 30
    Nurse 40 CRNA N3

Travel Reimbursement

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.