Request a Review of L&I's Policies Regarding Code Edits

IMPORTANT:  Providers who have concerns about individual bills or a claim decision need to follow the process outlined in File a Protest

Providers can request that L&I review its policies by submitting their concerns in writing provided:

  • The policy is related to professional services (as such it applies to all organizations that bill for professional services), and
  • There is a conflict between a provider's Coding Policy and L&I’s policy and both policies are based on a nationally recognized industry standard source such as the American Medical Association (AMA), CPT coding guidelines and conventions, local and regional Medicare policies, nationally recognized bundling edits, including CMS’s National Correct Coding Initiative (NCCI), or nationally recognized physician academy and society guidelines.  The conflict may result from a difference in the two nationally recognized sources or a difference in interpretation of the same nationally recognized source.

 

Specific examples of policy questions include but may not be limited to the following:

  • Bundled Services.
  • Pre and post op visits in the global period.
  • Incidental and Mutually Exclusive.
  • Modifier Validity.
  • Assistant Surgeon necessity.

 

This does NOT apply to medical policies or benefit determinations.  Specific examples include but may not be limited to the following.

  • Eligibility, Coverage and Benefits Limitations.
  • Medical Necessity Policy.
  • No Pre-Cert.
  • Fee Schedule or reimbursement allowances.
  • Waiting periods.
  • COB Workman's Comp.
  • Situations where a governing WAC is in place.
    • Per Washington Administrative Code 296-20-010, L&I’s payment policy supersede HCPCS Level I and II codes
  • State or Federal requirements.
  • Non-FDA approved (Experimental/Investigational service).
  • Contractual issues, e.g. patient cost share, referrals.


Providers requesting that L&I review its policies need to follow the process below.

Provider will:

1) Submit their concerns in writing to L&I

Address:  Health Services Analysis
Program Manager for Healthcare
Policy and Payment Methods
PO Box 44322
Olympia, WA 98504


The provider’s requests should include the following information:

  • Description of the issue that gives L&I a clear picture of the provider's concerns.
  • Explanation of why the provider does not agree with L&I’s current policy or interpretation, include the supporting alternative policy information and the source where it can be found.
  • Person's name/number as the point of contact within the provider’s organization.
  • As appropriate:
    • Relevant codes or code combination examples.
    • Specifics about associated bills that have been denied, e.g. EOB(s).

    Note: Since the request is related to policy review, L&I does not need/require bill specific information.  Since this is considered patient confidential information, they should not be submitted on an unsecured web site or unencrypted email.

 

2) Respond, within 15 calendar days, to requests from L&I for additional supporting documentation.
L&I will review the request to ensure that it falls within scope of this Best Practice Recommendation and that all necessary information is provided.  If L&I requests additional supporting materials, provider organizations should submit them within 15 calendar days.  The review cannot be considered without this information.

 

3) Provide significantly different information when submitting subsequent requests for review of the same policy.
Once a request for review of a specific policy has been submitted and a decision has been made by L&I, additional requests related to that same policy will no longer be processed by L&I unless supporting documentation is submitted that provides significantly different information than was submitted with the initial request.

 

L&I will:

  • Respond within 60 calendar days upon the receipt of the provider’s request, unless additional supporting documentation is required from the provider organization.
  • The request will be carried out with a spirit of collaboration with the provider.
  • The outcome will be formally communicated to the organization requesting the review.

 

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