(1) Hospitalization will be paid for proper and necessary medical treatment of the accepted condition(s). The department may develop and implement utilization management criteria which will be used to review inpatient hospital admissions. Reimbursement for hospitalization is limited to proper and necessary care for an accepted condition. Failure to comply with these criteria may result in delayed or reduced reimbursement to the provider as allowed under chapter
51.48 RCW. Ward or semi-private accommodations will be paid, unless the worker's condition requires special care.
(2) Discharge from the hospital shall be at the earliest date possible consistent with proper health care. If additional treatment is needed, discharge planning must include referral to a network provider. If transfer to a convalescent center or nursing home is indicated, prior arrangements should be made with the department or self-insurer. See WAC
296-20-091 for further information. The department may designate those diagnostic and surgical procedures which will be reimbursed only if performed in an outpatient setting. When procedures so designated must be performed in an inpatient setting for reasons of medical necessity, prior authorization must be obtained.
[Statutory Authority: RCW
51.36.010,
51.04.020, and
51.04.030. WSR 12-06-066, § 296-20-075, filed 3/6/12, effective 4/6/12. Statutory Authority: RCW
51.04.020(4) and
51.04.030. WSR 90-04-057, § 296-20-075, filed 2/2/90, effective 3/5/90; WSR 87-24-050 (Order 87-23), § 296-20-075, filed 11/30/87, effective 1/1/88; WSR 86-20-074 (Order 86-36), § 296-20-075, filed 10/1/86, effective 11/1/86; WSR 86-06-032 (Order 86-19), § 296-20-075, filed 2/28/86, effective 4/1/86. Statutory Authority: RCW
51.04.020(4),
51.04.030, and
51.16.120(3). WSR 81-01-100 (Order 80-29), § 296-20-075, filed 12/23/80, effective 3/1/81; Order 71-6, § 296-20-075, filed 6/1/71; Order 70-12, § 296-20-075, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-075, filed 11/27/68, effective 1/1/69.]