WSR 97-02-090

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[Filed December 31, 1996, 3:35 p.m.]

Date of Adoption: December 31, 1996.

Purpose: (1) To set standards of acceptable evidence of criminal acts. (2) To provide an additional factor for considering reducing debts due the department. (3) To give notice of certain treatment that the department will not cover.

Citation of Existing Rules Affected by this Order: Amending WAC 296-30-010, 296-30-060, 296-30-081, 296-30-120, 296-30-900, 296-31-010, 296-31-020, and 296-31-080.

Statutory Authority for Adoption: RCW 51.36.010.

Other Authority: RCW 7.68.030, 51.04.020 (1) and (4), 51.04.030, 7.68.080, 7.68.120.

Adopted under notice filed as WSR 96-21-015 on October 4, 1996.

Changes Other than Editing from Proposed to Adopted Version: All sections will be adopted as proposed except for those changed as the result of public comment and legal adviser recommendation.

WAC 296-30-010(11), the words "one or more of the following" have been added to precede the list of evidence items that can be considered. Public comment illustrated that the proposed language was not clear on whether one or all of the evidence items would be necessary to meet.

WAC 296-30-060, the word "medical" has been added to the proposed language so that the adopted language will read or other medical condition affecting the victim's capacity to act. The CVC program legal adviser recommends this change to clarify the department's intent.

WAC 296-31-020, the amendatory wording has been removed from the definition of "necessary treatment" and placed under a new definition titled "prohibited treatment." The amendatory wording has also been changed, but without changing the meaning or effect of the proposed language. This section drew the majority of public comment and these changes were made to address the concerns raised in those comments.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, amended 8, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 0, repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 8, repealed 0.

Effective Date of Rule: Thirty-one days after filing.

December 31, 1996

Dorette M. Markham

for Mark O. Brown

Director

AMENDATORY SECTION (Amending WSR 94-02-015, filed 12/23/93, effective 1/24/94)

WAC 296-30-010 Definitions. Whenever used in these rules, the following words mean:

(1) "((Innocent)) Victim" means any person whose injury was not the direct, proximate result of his or her consenting to, provoking, or inciting the criminal act that resulted in the injury.

(2) "Bodily injury" means any harmful or offensive touching, and includes severe emotional distress where no touching takes place when:

(a) Claimant is not the object of the criminal act and:

(i) The distress is intentionally or recklessly inflicted; and

(ii) The distress is inflicted by extreme or outrageous conduct; and

(iii) The claimant has a reasonable apprehension of imminent bodily harm; and

(iv) The claimant is in the immediate vicinity of the criminal act at the time the criminal act takes place.

(b) Claimant is the victim of the criminal act and:

(i) The distress is intentionally inflicted; and

(ii) The distress is inflicted by outrageous or extreme conduct; and

(iii) The claimant had a reasonable apprehension of imminent bodily harm.

(3) "Private insurance" means sources of recompense available by contract, such as life or disability insurance.

(4) "Public insurance" means any state or federal statutory welfare and insurance plan that compensates victims or their beneficiaries as a result of the claimed injury or death. This does not include state, federal, or private deferred income retirement plans.

(5) The test used to define "the result of" as used in RCW 7.68.070 (3)(a) is two pronged. First, it must be determined that cause in fact exists, and second, it must then be determined that proximate cause exists.

(a) Cause in fact exists if "but for" the acts of the victim the crime that produced the injury would not have occurred.

(b) Proximate cause exists if, once cause in fact is found, it is determined that the acts of the victim:

(i) Resulted in a foreseeable injury to the victim;

(ii) Played a substantial role in the injury; and

(iii) Were the direct cause of the injury.

(6) "Institutions maintained and operated by department of social and health services or the department of corrections" means those institutions in which the department of social and health services or the department of corrections assumes responsibility for medical coverage of the institution's residents.

(7) "Reasonable cooperation" generally exists when the claimant is:

(a) Willing to talk to police and give information to aid in the investigation; and

(b) Willing to assist in the prosecution of the alleged criminal.

(8) A person is "unjustly enriched" within the meaning of RCW 7.68.070(15) when it would be deficient in justice and fairness, or inequitable, to allow that person to obtain, or have control of or access to, benefits or compensation paid as a result of an injury to a victim of crime.

(9) "Department" means the department of labor and industries.

(10) "Services provided" means services covered under chapter 74.09 RCW or Title XIX of the Federal Social Security Act that are:

(a) Provided by health services providers with credentials recognized by the department for purposes of payment under chapter 51.36 or 7.68 RCW; and

(b) Available and equivalent to those services covered by the department under Title 51 or chapter 7.68 RCW.

(11) "Criminal act" means an act defined in RCW 7.68.020, the occurrence of which can be verified by the department or which is reasonably credible. Physically impossible acts, highly improbable acts for which verification is not available, or unverified memories of acts occurring prior to the age of two will not be accepted as reasonably credible. In evaluating evidence to determine verification of claimed criminal acts, the department will give greater weight to the quality, than to the quantity, of evidence. Evidence that can be considered for verification of claimed criminal acts includes, but is not limited to, one or more of the following:

(a) Police or other investigation reports.

(b) Child protective services or other government agency reports.

(c) Diaries or journals kept by victims and others.

(d) Third party reports from school counselors, therapists and others.

(e) Current medical examinations.

(f) Medical or psychological forensic evaluations. In the absence of other adequate forensic evaluation reports, independent assessments per WAC 296-31-069 (2) and (3) may be conducted when indicated.

(g) Legal and historical reports.

(h) Current and past medical and mental health records.

(i) Reports of interviews with the victim's family members, friends, acquaintances and others who may have knowledge of pertinent facts. When such interviews are necessary to determine eligibility, the victim will be given the choice of whether to allow the interviews to be conducted. The victim will also be given the understanding that eligibility may be denied if the interviews are not conducted. The department will act according to the victim's choice.

[Statutory Authority: Chapter 7.68 RCW. 94-02-015, 296-30-010, filed 12/23/93, effective 1/24/94. Statutory Authority: RCW 7.68.030, 7.68.070 (12) and (16) and 51.04.030. 89-23-004, 296-30-010, filed 11/3/89, effective 11/10/89. Statutory Authority: Chapter 7.68 RCW. 86-01-028 (Order 85-37), 296-30-010, filed 12/11/85; 85-03-060 (Order 85-3), 296-30-010, filed 1/15/85.]

AMENDATORY SECTION (Amending WSR 94-02-015, filed 12/23/93, effective 1/24/94)

WAC 296-30-060 Requirement to report criminal acts. (1) The following are examples under which the twelve-month reporting requirement in RCW 7.68.060 (1)(b) may be tolled:

(a) Unconsciousness or coma of victim.

(b) Youth of victim (because of age the victim is unaware that a crime has been committed against her).

(c) Rape trauma syndrome or medical condition affecting the victim's capacity to act.

(d) A report of an assault against a child made to children's protective services when the report is made within twelve months of when it reasonably could have been made.

(2) This list is not and should not be considered exhaustive but is for illustrative purposes.

[Statutory Authority: Chapter 7.68 RCW. 94-02-015, 296-30-060, filed 12/23/93, effective 1/24/94; 86-01-028 (Order 85-37), 296-30-060, filed 12/11/85; 85-03-060 (Order 85-3), 296-30-060, filed 1/15/85.]

AMENDATORY SECTION (Amending WSR 95-15-004, filed 7/5/95, effective 8/5/95)

WAC 296-30-081 Acceptance of rules and fees for medical and mental health services. Providing medical or counseling services to an injured crime victim whose claim for crime victims compensation benefits has been accepted by the department constitutes acceptance of the department's medical aid rules and compliance with its rules and fees. Maximum allowable fees shall be those fees contained in the publications entitled Medical Aid Rules and Fee Schedules and Crime Victims Compensation Program Mental Health Treatment Rules and Fees, less any available benefits of public or private collateral resources, except as follows:

The percentage of allowed charges authorized by WAC 296-23A-105: Payment for hospital inpatient and outpatient services, WAC 296-23A-155: New hospitals, WAC 296-23A-160(3): Excluded and included services, and WAC 296-23A-165: Out-of-state hospitals shall be equal to the percentage of allowed charges established by the department of social and health services under Title 74 RCW and WAC 388-87-070(6): Payment hospital inpatient services.

If any of the maximum allowable fees in the publications entitled Medical Aid Rules and Fee Schedules and Crime Victims Compensation Program Mental Health Treatment Rules and Fees is lower than the maximum allowable fees for those procedures established by the department of social and health services under Title 74 RCW, the Title 74 RCW fees are the maximum allowable fees for those procedures.

Prior to the establishment or amendment of the fee schedules, the department will give at least thirty calendar days notice by mail to interested persons who have made timely request for advance notice of the establishment or amendment of the fee schedules. To request advance notice of the establishment or amendment of the medical fee schedules, interested persons must contact the department at the following address:

Department of Labor and Industries

Health Services Analysis

P.O. Box 44322

Olympia, WA 98504-4322

To request advance notice of the establishment or amendment of the mental health fee schedules, interested persons must contact the department at the following address:

Department of Labor and Industries

Crime Victims Compensation Section

P.O. Box 44520

Olympia, WA 98504-4520

An injured victim shall not be billed for his or her accepted injury. The department shall be billed only after available benefits of public or private insurance have been determined. Bills must be submitted within ninety days from the date of service to be considered for payment. If insurance or public agency collateral resources exist, bills must be received within ninety days following payment or rejection by the resource. A copy of the payment or rejection must accompany the bill.

If the service provider has billed the injured victim and is later notified that the department has accepted the victim's claim, the provider shall refund to the injured victim any amounts paid ((that are in excess of the amounts that the victim is entitled to from public or private insurers)), and bill the department for services rendered at their usual and customary fees if such rates are in excess of the public or private insurance entitlements.

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030. 95-15-004, 296-30-081, filed 7/5/95, effective 8/5/95. Statutory Authority: Chapter 7.68 RCW. 94-02-015, 296-30-081, filed 12/23/93, effective 1/24/94; 92-23-034, 296-30-081, filed 11/13/92, effective 12/14/92; 92-16-033, 296-30-081, filed 7/30/92, effective 8/30/92; 86-01-028 (Order 85-37), 296-30-081, filed 12/11/85.]

AMENDATORY SECTION (Amending Order 85-37, filed 12/11/85)

WAC 296-30-120 Factors considered in order to modify debt due department. RCW 7.68.120 allows the department in the interest of justice or rehabilitation, to waive, modify, or adjust the debt owed to the department by any person found to have committed the criminal act for which crime victim benefits were paid. To determine whether or not the debt should be modified, waived or adjusted, the department shall consider the following factors:

(1) The gravity of the offense;

(2) Extent of injury to victim;

(3) Type of crime;

(4) Circumstances surrounding the criminal act;

(5) The assailant's attempts at rehabilitation:

(a) Rehabilitation program involvement;

(b) Employment efforts;

(c) Community involvement;

(6) Ability to pay:

(a) Income;

(b) Necessary expenses;

(c) Number and ages of dependents;

(7) Sentence imposed by the court;

(8) The impact on the victim of reducing the debt.

[Statutory Authority: Chapter 7.68 RCW. 86-01-028 (Order 85-37), 296-30-120, filed 12/11/85.]

AMENDATORY SECTION (Amending Order 85-37, filed 12/11/85)

WAC 296-30-180 Payment of benefits to prevent unjust enrichment. RCW 7.68.070(15) prohibits the department from paying any benefits or compensation to the person who caused a crime victim's injuries, or to any other person if that person would be unjustly enriched by the benefits. In some situations, as when a child is injured by a parent or a spouse by the other spouse, there is a danger that the injuring person will divert to his or her own use the benefits or compensation intended for the victim.

To prevent this possibility, the department may on its own motion or the motion of the victim or his or her guardian, request that the victim or other responsible adult establish (1) a trust for which the trustee shall be a neutral third person; or (2) a savings or checking account for which a neutral third person must cosign all withdrawals or checks. Crime victims compensation benefits shall then be deposited in the established account.

The department shall continue to pay medical providers directly.

[Statutory Authority: Chapter 7.68 RCW. 86-01-028 (Order 85-37), 296-30-180, filed 12/11/85.]

AMENDATORY SECTION (Amending Order 85-3, filed 1/15/85)

WAC 296-30-900 Effective date of amendatory acts. (((1))) The statute in effect at the time the ((criminally caused injury)) criminal act occurred is the controlling law.

[Statutory Authority: Chapter 7.68 RCW. 85-03-060 (Order 85-3), 296-30-900, filed 1/15/85.]

AMENDATORY SECTION (Amending WSR 95-15-004, filed 7/5/95, effective 8/5/95)

WAC 296-31-010 Mental health treatment overview. (1) The crime victim compensation program provides mental health treatment to victims of crime, except for the provisions of WAC 296-30-025 (6)(b), secondary to treatment available from any other public or private insurance, who are eligible for compensation under the provisions of chapter 7.68 RCW. Eligible claimants are entitled to receive proper and necessary mental health treatment.

(2) Services and treatment are limited to those procedures which are proper and necessary, and at the least cost, consistent with accepted standards of mental health care which will enable the claimant to obtain maximum recovery and/or:

(3) In the case of a permanent partial disability, treatment or services are not to extend beyond the date when permanent partial impairment or disability compensation is awarded. No treatment or services will be authorized beyond the point that the accepted condition is fixed and stable.

(4) In the case of a permanent total disability, treatment is not to extend beyond the date on which the claimant is placed upon a permanent pension roll except that in the sole discretion of the department continued treatment for conditions previously accepted by the department may be allowed when such treatment is deemed necessary to protect the claimant's life or to provide for the administration of therapeutic measures. This includes payment of prescription medications necessary to alleviate continuing pain resulting from the accepted condition but does not include those controlled substances scheduled by the state board of pharmaceuticals as schedule I, II, III, IV substances under chapter 69.50 RCW.

(5) Mental health treatment requiring preauthorization:

Inpatient hospitalization;

Individual therapy exceeding one hour per week;

Group therapy exceeding one session per week;

Concurrent treatment;

Family therapy (((including all therapy provided to family members))) to family members of sexual assault victims beyond twelve sessions;

Therapy for survivors of victims of homicide beyond twelve sessions;

Electroconvulsive therapy;

Neuropsychological evaluation (testing);

Day treatment for seriously ill persons less than eighteen years of age;

Referrals to special programs.

Requests for authorization must be in writing and include a statement of:

(a) The condition(s) diagnosed;

(b) ICD-9-CM and/or DSM-III-R or DSM-IV codes;

(c) The relationship of the condition(s) diagnosed to the assault, if any;

(d) An outline of the proposed treatment program, its length and components, procedure codes, and expected prognosis.

(6) Rejected and closed claims. Therapy for eligible survivors of victims of homicide can be provided on closed claims:

No payment will be made for treatment or medication on rejected claims or for services rendered after the date of closure of a claim.

When the department has denied responsibility for an alleged crime victim injury or condition, the only services which will be paid are those which were carried out at the specific request of the department and/or those assessment or diagnostic services which served as a basis for the adjudication decision. Following the date of the order and notice of claim closure, the department will be responsible only for those services specifically requested or those assessments and/or diagnostic services necessary to complete and file a reopening application.

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030. 95-15-004, 296-31-010, filed 7/5/95, effective 8/5/95. Statutory Authority: RCW 43.22.050. 92-23-033, 296-31-010, filed 11/13/92, effective 12/14/92.]

AMENDATORY SECTION (Amending WSR 95-15-004, filed 7/5/95, effective 8/5/95)

WAC 296-31-020 Definitions. This section explains the department's definitions of terms used throughout the sections as they apply to claimants.

Acceptance, accepted condition: Determination, in writing, by a qualified representative of the department, that reimbursement for the diagnosis and rehabilitative treatment of a claimant's mental health condition are the responsibility of the department. The condition being accepted must be specified by one or more diagnostic codes from the current edition of the International Classification of Diseases, Clinically Modified (ICD-CM), or by DSM III-R, or DSM IV and by use of words to describe the symptoms connected to or citing ICD-CM or DSM III-R or DSM IV diseases.

Authorization: Notification, in writing or by telephone, by a qualified representative of the department, that specific necessary treatment, services, or equipment recommended by a provider for the diagnosis or rehabilitative treatment of an accepted condition will be reimbursed by the department. Providers must insure they maintain records indicating the name of the qualified representative who authorizes treatment or equipment.

Claimant: A person who submits, or on whose behalf is submitted, an application for benefits under the Crime Victims Act.

Consultation: The services rendered by a mental health provider whose opinion or advice is requested by the attending (treating) mental health provider, or agency, or by the department in the evaluation and/or treatment of a claimant. Case management or case staffing does not constitute a consultation. Treatment of a claimant is not a consultation.

Crisis intervention: Therapy to alleviate the most pressing problems and attempt to use the crisis as an opportunity for positive change; the vital mental and safety functions of the client are stabilized by providing support, structure and, if necessary, restraint.

Disability awards for mental health conditions: Direct monetary compensation that may be provided to an eligible claimant who is either totally temporarily disabled, permanently partially disabled, or totally permanently disabled resulting from an accepted condition. Under Washington law, permanent disability awards are based solely on mental impairment due to the accepted injury or conditions without consideration of economic factors. Disability rating exams must be provided by a physician.

Elective nonemergent hospital admission: Placement of the claimant in an acute care hospital or residential treatment facility for mental health treatment of a claim related mental health condition which may be safely scheduled in advance without jeopardizing the claimant's health or treatment outcome.

Emergent hospital admission: Placement of the claimant in an acute care hospital, psychiatric hospital, or, residential treatment facility for treatment of a claim related mental health condition of an unforeseen or rapidly progressing nature which, if not treated in an inpatient setting, is likely to jeopardize the claimant's health or treatment outcome.

Family therapy: Therapy involving the therapist, and one or more members of the claimant's family (excluding the perpetrator if also a family member) and which centers on issues resulting from the claimant's sexual assault pursuant to WAC 296-30-080.

Group therapy: Therapy involving the claimant, the therapist, and one or more clients who are not related to the claimant and which includes issues both related to the claimant's assault and pertinent to other group members, not necessarily related to the claimant's assault.

Homicide survivor: An immediate family member of a homicide victim as the result of a criminal act committed on or after July 1, 1992. Homicide survivors may receive appropriate counseling to assist them with the immediate, near term consequences of the related effects of the homicide. Family members applying for survivor counseling benefits must complete and submit a Request for Homicide Survivor Counseling Benefits Form (F800-057-000) once a claim has been established and allowed by the department. Maximum allowable fees shall be those fees contained in the publication entitled Crime Victims Compensation Program Mental Health Treatment Rules and Fees, less any benefits of public or private collateral resources available to each eligible family member.

Immediate family members: Any claimant's parents, spouse, child(ren), siblings, grandparents, and those members of the same household who have assumed the rights and duties commonly associated with a family and who hold themselves out as a family unit.

Individual therapy: Therapy provided on a one to one basis between a therapist and claimant.

Mental health services provider: Any person, firm, corporation, partnership, association, agency, institution, or other entity providing any kind of mental health services related to the treatment of a claimant. This includes, but is not limited to, hospitals, psychiatrists, psychologists, advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing, registered and/or certified master level counselors, and other qualified service providers licensed, registered and/or certified with the department of health and registered with the crime victims program. (Refer to WAC 296-31-030 for specific details.)

Modified work status: When the claimant is not able to return to previous work, but is capable of carrying out work of a lighter, or otherwise different nature.

Necessary treatment: Those health services or treatments which, in the opinion of the director or his or her designee are:

Proper and necessary for the diagnosis or rehabilitative treatment of an accepted condition;

Reflective of accepted standards of good practice within the scope of the provider's license, certification, or registration;

Not delivered primarily for the convenience of the claimant, the claimant's attending provider, or any other provider; and

Provided at the least cost and in the least intensive setting of care consistent with accepted standards of care/accepted therapeutic practice and with the other provisions of this definition. Services which are inappropriate to the accepted condition, or which present hazards in excess of the expected mental health benefits, are not considered necessary. Services which are obsolete are not authorized. Services which are controversial, experimental, or investigational are presumed not to be consistent with accepted standards of care and shall only be authorized on an individual case basis with written authorization for the service from the department.

Office notes: Written records of treatment, or other work products, documenting specific charges billed, as opposed to reports of evaluation and progress independently submitted to the department or to other parties.

Permanent partial disability: Providers are required to notify the department of any claimant's accepted condition where permanent functional impairment or loss is indicated after maximum rehabilitation has been achieved, which is determined to be stable and fixed at the time the evaluation is made. The department will arrange to have impairments rated using the category system under WAC 296-20-200 et al.

Prohibited treatment: The department will not allow or pay for any therapies which focus on the recovery of repressed memory or recovery of memory which focuses on memories of physically impossible acts, highly improbable acts for which verification should be available, but is not, or unverified memories of acts occurring prior to the age of two.

Regular work status: When the injured claimant is capable of returning to his/her regular work, the attending provider must notify the claimant and the department of the specific date of release to return to regular work. Time loss compensation will be terminated on the release date. Further treatment may be allowed as requested by the attending provider if the condition is not stable or fixed and treatment is needed for the accepted condition.

Repressed memory: A condition of not having or had conscious memory of an act. For the purpose of these rules describing this condition under this section the definition means that a claimant regained conscious memory of victimization caused by a criminal act committed against them as a minor.

Temporary partial disability: Partial time loss may be paid when the claimant can return to work on a limited basis, or, return to a lesser paying job is necessitated by the accepted condition. However, the claimant must have a reduction in wages of at least five percent before loss of earning power can be paid.

Termination of treatment: When treatment is no longer required because the accepted condition for which the claim was allowed has become stable, the provider must submit a report indicating the date the condition became stable to the department. This is necessary to initiate closure of the crime victim's compensation claim.

Time loss certification: Certification from a physician, or mental health professional qualified to treat under the Crime Victims Act, based upon findings which are specific symptoms that an accepted condition of a claimant either partially or totally incapacitates the claimant from returning to work. Such symptoms may include, but are not limited to: Anxiety, depression, loss of appetite, weight loss, flat affect, inability to concentrate, inability to complete tasks. ((The department requires that all claims for time loss compensation must be certified by a physician.))

Total permanent disability: A condition permanently incapacitating a claimant from performing any work at any gainful occupation.

Total temporary disability (time loss): The claimant is temporarily unable to return to any type of reasonably continuous gainful employment as a direct result of an accepted condition. Time loss compensation will be paid if the victim was employed on the date of their criminal injury, or, if not, if the victim was employed three or more consecutive months during the twelve months immediately preceding the date of the assault.

Utilization review: The assessment of a claimant's mental health care for assurance that it is necessary and of good quality. Assessments typically consider the appropriateness of the place of care, level of care, and the duration, frequency or quantity of services provided in relation to the accepted condition being treated.

Victim: A person who suffers bodily injury or death as the proximate result of a criminal act of another person, the claimant's own good faith and reasonable effort to prevent a criminal act, or his or her good faith effort to apprehend a person reasonably suspected of engaging in a criminal act. For the purposes of receiving benefits, "victim" is interchangeable with "employee" or "worker" as defined in the Industrial Insurance Act. For the purpose of these rules "bodily injury" means any harmful or offensive touching, and includes severe emotional distress where no touching takes place as defined and under the conditions outlined in WAC 296-30-010(2).

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030. 95-15-004, 296-31-020, filed 7/5/95, effective 8/5/95. Statutory Authority: Chapter 7.68 RCW. 94-02-015, 296-31-020, filed 12/23/93, effective 1/24/94. Statutory Authority: RCW 43.22.050. 92-23-033, 296-31-020, filed 11/13/92, effective 12/14/92.]

AMENDATORY SECTION (Amending WSR 95-15-004, filed 7/5/95, effective 8/5/95)

WAC 296-31-080 Billing procedures. (1) All services rendered must be in accordance with these mental health treatment rules. The department may reject bills for services rendered in violation of these rules. The claimant may not be billed for services rendered in violation of these rules. However, claimants may be billed if they fail to keep or miss a properly scheduled appointment.

Providers shall bill their usual and customary fee for services. If a usual and customary fee for any particular service is lower to the general public than listed in the fee schedules, the practitioner shall bill the department at the lower rate.

(a) Bills must be itemized on department forms or other forms which have been approved by the department. Physicians, advanced registered nurse practitioners, psychologists, and masters level mental health counselors may use the National Standard HCFA 1500 Health Insurance Claim Form or the department's statement for crime victim services. When billing for treatment of a family member other than the claimant, you must identify the family member by name and relationship to the claimant. Hospitals use the UB-92 billing form for institution services and the National Standard HCFA 1500 Health Insurance Claim Form for professional services.

(b) Bills must specify the date and type of service, the appropriate procedure code, the condition treated, and the charges for each service.

(c) Every bill submitted to the department must be completed to include the following:

(i) Claimant's name and address;

(ii) Claimant's claim number;

(iii) Date of injury;

(iv) Referring provider's name;

(v) Dates of service;

(vi) Place of service;

(vii) Type of service;

(A) Psychiatrists and psychologists use type of service 3.

(B) Master level counselors use type of service M.

(C) Advanced registered nurse practitioners (ARNP) use type of service N.

(viii) Appropriate procedure code or hospital revenue code((,));

(ix) Description of service; if mental health patient is not the claimant, give name and relationship to the claimant;

(x) Charge;

(xi) Units of service;

(xii) Total bill charge;

(xiii) Provider of service;

(xiv) Group, clinic, center, or facility name;

(xv) Billing address;

(xvi) Federal tax information;

(A) Federal tax identification number; or

(B) Social Security number.

(xvii) Date of billing;

(xviii) Submission of supporting documentation required under (f) of this subsection;

(xix) Private or public insurance eligibility and amounts paid.

(d) Responsibility for the completeness and accuracy of the description of services and charges billed rests with the provider rendering the service, regardless of who actually completes the bill form.

(e) Providers are urged to bill on a monthly basis. Bills must be submitted within ninety days from the date of service to be considered for payment. If insurance or public agency collateral resources exist bills must be received within ninety days following payment or rejection by the resource. A copy of the payment or rejection must accompany the bill.

(f) The following supporting documentation must be maintained and submitted when billing for services, as may be appropriate:

(i) Intake evaluation;

(ii) Progress reports;

(iii) Consultation reports;

(iv) Special or diagnostic study reports;

(v) Independent assessment or closing exam reports;

(vi) For BR procedures - see WAC 296-31-090 for requirements;

(vii) Claimant public or private insurance information.

(g) The claim number must be placed in the upper right hand corner on each bill and on each page of reports and other correspondence.

(h) Rebills. If a provider does not receive payment or notification from the department within ninety days, services may be rebilled. Rebills must be submitted for services denied if a claim is closed or rejected and subsequently reopened or allowed. Rebills should be identical to the original bill: Same charges, codes, and billing date. The statement "rebill" must appear on the bill.

(i) Any inquiries regarding adjustment of charges must be submitted within ninety days from the date of payment to be considered.

(j) Any denied charge may be protested in writing to the department or appealed to the board of industrial insurance appeals.

(2) Allowance and payment for medication. The department will pay for medications or supplies dispensed for the treatment of conditions resulting from a crime victim injury and/or conditions which are retarding the recovery from the claimant's condition, for which the department has accepted temporary responsibility. Specific information governing allowance and payment for medication is contained in WAC 296-20-17001.

(3) Payment of out-of-state providers.

(a) Providers of mental health services ((in the bordering states of Oregon and Idaho shall bill and be paid according to Washington state rules)) located outside of the state of Washington shall bill their usual and customary fees and will be paid according to the Washington state crime victims compensation program mental health treatment rules and fees.

(b) ((Providers of health services in other states and other countries shall be paid at rates which take into account:

(i) Payment levels allowed under the state of Washington crime victims compensation program rules;

(ii) Payment levels allowed under crime victims compensation or workers compensation programs in the state of the provider's place of business; and

(iii) The usual, customary, and reasonable charges in the state and city of the provider's place of business.)) Independent medical exams (independent assessments) shall be billed and paid according to the examiner's usual and customary fee.

(c) In all cases these payment levels are the maximum allowed to providers of services to claimants. Should a provider's charge exceed the payment amount allowed under the state of Washington crime victim compensation program rules, the provider is prohibited from charging the claimant for the difference between the provider's charge and the allowable rate. Providers violating this provision are ineligible to treat claimants as provided by these mental health rules and are subject to other applicable penalties.

(d) Only those diagnostic and treatment services authorized under the state of Washington mental health rules may be allowed by the department. As determined by the department, the scope of practice of providers in bordering states may be recognized for payment purposes, except that in all cases WAC 296-20-03002 (treatment not authorized) shall apply. Specifically, services permitted under crime victims compensation programs in the provider's place of business, but which are not allowed chapters 296-20, 296-30, and 296-31 WAC of the state of Washington, may not be reimbursed. When in doubt, the provider should verify coverage of a service with the department.

(e) Out-of-state hospitals will be paid according to WAC 296-30-081.

[Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030. 95-15-004, 296-31-080, filed 7/5/95, effective 8/5/95. Statutory Authority: Chapter 7.68 RCW. 94-02-015, 296-31-080, filed 12/23/93, effective 1/24/94. Statutory Authority: RCW 43.22.050. 92-23-033, 296-31-080, filed 11/13/92, effective 12/14/92.]

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