About the Insurer Activity Prescription Form (APF)

The APF has been updated. Please use the version dated July 2009 (7/09) on the bottom of the front page. Recycle all of the old APFs in your office (dated 8/07). Guidelines for when to use the APF have not changed. Go to the "Authorization" tab above for more explanation.

The APF communicates:

• Work status,
• Work-related physical restrictions,
• Verification of time-loss, if appropriate, and
• Treatment plans.

Note: Health care providers in the Centers of Occupational Health & Education and the Orthopedic/Neurologic Pilot Projects will continue to follow the APF use and billing instructions provided by those projects.

Health care providers will continue to be paid for activities supporting return-to-work including:

• Consultation with employers and VRCs, and
• Review of job descriptions and job analyses.

State Fund employers can clarify physical capacity information by contacting the attending provider or obtain it by:

• Using attending provider-completed APFs that are a part of the worker's claim file and can be viewed in L&I's Claim and Account Center,
• Asking attending providers for information regarding return to work. Both VRCs and State Fund employers may seek:
  • concurrence with a performance based physical capacities evaluation (PBPCE).
  • authorization for worker to participate in a PBPCE.

Effective September 14, 2009, Private VRCs may request an APF from the provider if clarification or updated physical capacity information is needed or wroker condition has changed.

• Return the APF to the department to ensure payment for completion of the form.
• You are encouraged to fax the APF to expedite return to work services.

Additionally, VRCs may ask a provider to review and respond to:

• job modification or pre-job accommodation.
• proposed work hardening program.
• plan for graduated, transitional, return-to-work.
• request clarification of information on an APF that relates to return-to-work.

Attention Providers:

You may respond to an employer’s or VRC's request for a worker's physical restrictions:

• to help with return to work efforts,
• if you have not provided that information on an Activity Prescription Form (APF) submitted with the report of accident or at the insurer’s request.
• if the restrictions you have previously provided on an APF have changed.

 Bill code 1074M for this service.

If you’ve recently submitted a completed APF and nothing has changed, inform the employer or VRC that they can obtain the workers’ physical restrictions from the insurer.

Call the Provider Hotline 1-800-848-0811 with your questions about the APF.

Ordering the Insurer Activity Prescription Form

The insurer will supply healthcare providers with an APF to complete with their request. Self-insurers or their third party administrators may send customized APFs.

Healthcare and vocational providers: Keep a supply of APFs in your office for submitting with a report of accident or Physician Intial Report (PRI) when there are physical restrictions. There are several ways to obtain APFs:

• Print one now
• Electronic form, contact Joanne McDaniel
• Order online

Healthcare and vocational providers: Fill out the order form below and L&I will mail the APFs to you.

Order by fax

Healthcare and vocational providers: Fax your order to the L&I Warehouse at 360‑902‑4525. Include in your faxed request the following information:

• "Insurer Activity Prescription Form - F242-385-000".
• Your name.
• Your company name.
• Mailing address.
• Telephone number.
• Quantity (copies are singles sheets, not pads).

Call the Provider Hotline 1-800-848-0811 for questions about the APF.

Completing the Insurer Activity Prescription Form

How do I complete the APF?

Health care providers must complete the form. Writing "See chart notes" on the form is not acceptable. Chart notes are essential and must still be submitted for every visit billed.

What is required on the form to ensure payment?

Clinical scenarios and form samples

Note: If a worker has more than 1 injured body part in the "Note to Claim Manager", indicate how you have marked the "Doctor's Estimate of Physical Capacities." For example: 1=left knee, 2=left shoulder.

Sample 1: Worker requires temporary, modified duty while recovering from injury. Complete all sections. See sample 1 (67 KB PDF).

Sample 2: Worker is off work due to an industrial injury or occupational disease. Complete all sections. See sample 2 (68 KB PDF).

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

Authorization requirements

Health care providers are only authorized to submit APFs along with a report of accident (ROA) or Physician Intial Report (PRI). The ROA must show the worker has physical work-related restrictions that must be accommodated for light duty work.

If the insurer requires additional APFs, they will send a request letter with a blank APF.

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

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 or Physician Intial Report (PRI) of accident where the worker has physical restrictions.
  or
• 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.
• 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

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:

• CPT® codes 99441 to 99443 and 98966 to 98968.
• CPT® code book for entire descriptions.
• For complete payment policies and documentation requirements, see the Payment policies (1,189 KB PDF / 7 min ).

 Get Help Downloading Files (files open in a new window).

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.

What are the documentation and recordkeeping requirements?

What kind of documentation do I need to do?

• SOAPER notes and reports are required as usual, even when the insurer requests an APF.
• Chart notes in SOAPER format include:
• S - Worker's subjective complaints.
• O - Doctor's objective findings.
• A - Doctor's assessment.
• P - Plan.
• E - Employment.
• R - Restrictions.
• If there are multiple claims for a worker, put all claim numbers on the:
• APFs
• Bills,
• Chart notes and
• Reports.
• Send the completed APF to the insurer.

Give a copy of the APF to the worker, so they can show it to their employer.

For more information on chart note and report requirements, see pages 24-25 of the Attending Doctors' Handbook (F252-004-000).

What are the recordkeeping requirements?

Keep APFs, chart notes, reports and other information in your files for a minimum of 5 years for audit purposes.

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