Insurer Activity Prescription Form

How do health care providers bill for using the Insurer Activity Prescription Form?

Payment Policies

Activity Prescription Forms (APF) are payable only when all relevant sections of the form are completed, legible and:

  • When submitted with a Report of Accident (ROA) or Providers Initial Report (PIR) where the worker has physical restrictions.
  • Upon the request from the insurer or vocational counselor.

Note: APFs are not payable when submitting an Application to Reopen Claim (F242-079-000). Insurers may request APFs on reopened claims.

Who can bill for filling out the APF

The APF will be payable to:

  • Doctors, as defined in WAC 296-20-01002 including:
    • Attending doctors.
    • Transfer doctors.
    • Concurrent care doctors.
    • Consultants.eee
  • Advanced Registered Nurse Practitioners (ARNPs).
  • Physician Assistants (PAs).

Who can not bill for filling out the APF

Occupational therapists, physical therapists, office staff and others cannot be paid for working on or completing the APF form.

Billing codes and fees

Code Fee Description Limit
1074M $30.51 Written response to VRC or employer requests for information on return to work As requested, but not to exceed once per provider per worker per day
1073M $49.57 Insurer Activity Prescription Form (F242-385-000) As requested, but not to exceed 1 APF, per provider, per worker, per day.

Billing codes for phone calls to insurer, employer, and vocational rehab counselors

To bill health care providers' telephone call/consultation regarding care of injured workers, use:

Electronic billing

For information on billing L&I electronically, see our Electronic Billing site. Payment is much faster than using paper billing.

Paper billing

Submit bills by completing APFs on CMS 1500 forms (F245-127-000).

For questions about the APF, call Provider Hotline 1-800-848-0811.

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