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File accident reports on time to receive the full fee

Beginning July 1, if your office files an accident report more than 5 business days after an injured worker’s first treatment, you will be paid less than if you get the form to us right away.

Research shows that when injuries are reported quickly, worker outcomes improve. We appreciate your care for injured workers. By submitting accident reports promptly, you will help us do a better job delivering services at the right time to injured workers and their employers. 

Effective July 1, 2012
Payments for Report of Industrial Injury or Occupational Disease (ROA),
or Provider’s Initial Report (PIR)
If the report is received
(following date of first treatment)
Maximum payment
Within 5 business days $38.14
6–8 business days $28.14
9 or more business days $18.14

About payment adjustments on State Fund claims

Who can get paid for completing the ROA/PIR?

A provider may be paid for completing a ROA or PIR if they have a valid provider account number and are licensed as one of the following:

  • MD.
  • DO.
  • DC.
  • ND.
  • DPM.
  • DDS.
  • ARNP.
  • PA-C.
  • OD.

Billing requirements

  • Bill for only 1 ROA or PIR per claim, using local code 1040M.
  • Submit the ROA or PIR to the insurer immediately following the first treatment date.
  • Complete the ROA using instructions on form F242-130-000 (English) or F242-130-999 (Spanish).
  • Complete the PIR using instructions on the back of form F207-028-000.   If you need additional space:
    • Attach the information to the application, and
    • Include the claim number at the top of the page.

Note: *Reimbursement amount is based on the date the healthcare provider includes in box 3 of
the ROA (“Date you first saw patient for this condition.”).  If that box is blank, the payment system will auto-calculate to the lowest reimbursement, i.e., $18.14.

Questions about payments for ROAs?

  • Call the Provider Hotline, 800-848-0811.

Related information

Filing claims — the provider’s responsibilities

WAC 296-20-06101

WAC 296-20-025

RCW 51.28

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