Claim Filing Responsibilities
Initiating and Filing
You have the opportunity to start a worker on their path to recovery. Unlike other health insurance systems, in workers’ compensation, a claim is not a bill. A claim is a file of important information about the worker, the injury or exposure, the specific job, and the employer.
The claim is monitored and managed by a person (the claim manager). It will benefit you and the worker to know when and how to file a claim properly. You can even file a claim online. Getting the claim started soon and in the right way, can make a positive difference during the initial treatment phase, will reduce the burden for you, and can lead to better outcomes for the worker.
The Report of Accident
It all starts here
The Report of Accident (ROA) is the first notice that a worker has been injured, exposed to, or diagnosed with an occupational or infectious disease in the workplace. L&I or the self-insured employer should receive the reports within five days of initial treatment or diagnosis; two days is the best practice. If you delay mailing or filing the Report of Accident, your patient could face significant hardship, and claim costs and employer rates may rise. You can order forms from L&I’s warehouse.
For L&I State Fund employers, file the ROA online with File Fast or file paper copy by fax or mail.
For self-insured employers, the worker completes the Self Insurer Accident Report (SIF-2) at the employer and you and the worker complete the Provider’s Initial Report (PIR).
Occupational Disease Claims
A different process
Occupational diseases differ from industrial injuries in that exposure to hazardous conditions may occur over time, and symptoms may not appear for months or years. Occupational diseases must meet several legal requirements as well as clinical case definitions. There are also filing deadlines for these claims.
When a worker is exposed to a hazardous element or condition, symptoms may not appear for months or even decades. When this happens, you’ll want to know what services are covered and payable; plus you need to know what diseases or exposures must be reported to public health officials. Learn more about how we manage occupational diseases.
Activity Prescription Forms
Roadmap to recovery
Attending Providers (APs) are the department’s best partner in helping injured workers heal and return to work. The Activity Prescription Form (APF) is a way of communicating your recommendations with everyone involved in the claim. The APF allows you to provide a summary of the worker’s condition and detail what the worker is medically capable of doing. Make sure to pay special attention to the category for objective medical findings. Completing the APF ensures timely benefit payments and reduces delays in authorizing treatment. You can even be paid for completing and sending it in!
Reports and Documentation
It's worth getting it right the first time
Yes, we require paperwork. To help you “get it right” and save time, follow the instructions for what documentation is needed and when (WAC 296-20-06101). You are already familiar with subjective, objective, assessment, and plan (SOAP) notes; we add E and R to that to address a worker’s Employment options and their Restrictions to recovery (restrictions, barriers, or unrelated conditions preventing recovery or return to work). Remember, the goals are to help the worker heal, return to work, and ultimately prevent disability. You are an important person in helping achieve these goals.
Protests and Appeals
How to work with the system
Workers, employers, and providers don't always agree with L&I's decisions, and they have certain protest and appeal rights. Whether or not you, the attending provider, protest a decision, you may be asked to provide input when this occurs. For example, requests to reconsider closing a claim are based on the medical condition, treatment program, and prognosis, information you may need to provide. If, after reviewing the case, L&I doesn't change its decision, one can appeal to the Board of Industrial Insurance Appeals (BIIA), an independent body created by the legislature to hear such cases. More information is available at Appeal an L&I Claim Decision.
Closing and Reopening a Claim
When care is needed again
When a worker is at maximum medical improvement, L&I will need documentation explaining his or her final functional status. If appropriate, L&I will close the claim. After claim closure, some workers experience a worsening of their previous work-related condition. If you believe the worker needs treatment, you can file a reopening application. You must be in L&I’s Medical Provider Network to be paid for services related to the reopening application (such as office visit and diagnostic studies). If the claim is reopened, only services provided within 60 days before L&I’s receipt of the reopening application are payable.
Pensions
When everything that can be done, has been done
What can you do for an injured worker when, despite the best efforts, there is no more progress toward function and recovery? Determining disability is an important part of the APs role. If the worker is totally and permanently disabled, he or she becomes eligible for pension benefits. In general, medical services stop once a worker is placed on pension; however, the supervisor of industrial insurance, solely in his or her discretion, may authorize continued medical and surgical treatment for conditions previously accepted by the department when such medical and surgical treatment is deemed necessary by the supervisor of industrial insurance to protect such worker's life. (RCW 514.36.010(4)). If you find yourself treating a worker who appears to be headed this direction, learning how L&I determines total and permanent disability can help you help the worker.
Chemically Related Illness (CRI)
Specialized L&I Unit
CRI refers to a variety of health problems caused by exposure to occupational and/or environmental chemicals like solvents (such as paint), metals (such as lead), and irritants (such as formaldehyde). Associated health problems may include occupational asthma, lead poisoning, and solvent-induced neuropathies. Employers are required to provide workers with detailed information about the chemicals to which they are exposed so ask your patient or the employer for these when taking an occupational history. CRI claims are reviewed by a special L&I claims unit.