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First Fills

This information is effective January 1, 2008.

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 a new prescription for the original injury before the claim is accepted.
  OR
• If it is a federal or self-insured claim.

Payment for initial prescription drugs shall be based on L&I's fee schedule. Your bill must be received by L&I within 1 year of the date of service.

Using the point-of-sale (POS) system

To obtain a valid SF 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 reject 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.

 

Authorization request for initial prescription

• Call PDL hotline: 1−888−443−6798 or 360−902−4321 Monday through Friday, 8 a.m. to 5 p.m. PST.
• If the pharmacy receives a prescription after normal business hours or during weekends or Washington State holidays, you may:
  • Dispense an emergency supply of the drug and request authorization the next business day.
  • Dispense the drug under the worker's insurance and request authorization the next business a day.
• When you call L&I, you will need to give a diagnosis of, or information on, the condition being treated.

How to identify a SF claim

SF 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).

Transaction Header Segment Table

This 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 non-preferred drug by non-preferred drug by non-endorsing practitioner.