Billing L&I for Pharmacy Services

First Fills

L&I will pay pharmacies or reimburse workers for prescription drugs prescribed during the initial visit only.

L&I will not pay:

  • For refills of the initial prescription or any additional prescriptions for the original injury before the claim is accepted.
    OR
  • If it is a federal or self-insured claim.
    OR
  • If it is prescribed by a provider who has been excluded from the provider network.

Payment for initial prescription drugs shall be based on L&I's fee schedule. Your bill must be received by L&I within one year of the date of service.

Using the point-of-sale (POS) system

To obtain a valid State Fund claim number for billing, you must see a copy of the report of accident (ROA) or the claim ID card. See an example of the ROA with attached ID card (217 KB PDF / 1 min).

When the prescription meets criteria for guaranteed payment, the POS system will send rejection code 52 or 67 with the following information:

  • Maximum allowed amount: $XX.XX and
  • A message: "Prescription qualifies for first fill; submit prior authorization number 46484254557 after verifying claim number from report of accident or claim ID card."

Remember to submit a valid prior authorization qualifier (08) along with the authorization number.

How to identify a State Fund claim

State Fund claim numbers are alpha-numeric, consisting of 7 characters. They begin with B, C, F, G, H, J, K, L, M, N, P, X, or Y followed by 6 digits or double alpha (e.g. AA, AB, AG) followed by 5 digits. See an example on this ROA with attached ID card sample (217 KB PDF / 1 min).

The following table shows the required entries in the Transaction Header Segment of the NCPDP 5.1 specifications.

See RCW 51.36.010 (www.leg.wa.gov) for more information.

Transaction Header Segment
Transaction Header Segment
Field name Data element number Required status Valid values/comments
Prior authorization type code 461-EU Optional 08 - Payer defined exemption for use with reject code 52 or 67.
Prior authorization number submitted 462-EV Optional Enter prior auth 46484254557 after verify the claim number from the ROA or claim ID card for initial prescription.
Dispense as written/product selection code 408-D8 Optional Valid values:
0=No product selection indicated (substitution permitted)
1=Substitution not allowed by prescriber (DAW)
6=Override for emergency supply of drug requiring prior authorization.

Refill(s) and/or additional prescription dispensed before claim acceptance

  • You may charge the injured worker for the prescription and submit the bill with the amount paid in the patient paid amount or co-pay field. L&I will capture the bill and reimburse the injured worker if and when the claim is allowed.
  • You may submit a paper bill. L&I will suspend the bill and reimburse you when the claim is allowed.
  • You may wait until the claim is allowed and then submit it through the POS system.

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