The Industrial Insurance Act (Act) provides that a worker who is injured in the course of employment or injured or disabled from an occupational disease is entitled to workers' compensation benefits.  Benefits may include medical, temporary time-loss, vocational rehabilitation, and permanent disabilities benefits.  The Department of Labor and Industries (Department) administers the workers' compensation system.

Worker’s Choice of Provider.

An injured worker must seek care from a provider within the Department's medical provider network, except for an initial or emergency visit.  Within the Department's medical provider network, a worker is entitled to seek care from a provider of the worker's choice. 

Coverage Decisions and Treatment Guidelines.

A network provider must follow the Department's coverage decisions, treatment guidelines, and policies, and when appropriate for the patient, other national treatment guidelines.

Utilization Review.

The Department contracts with a utilization review provider to review requests for certain medical services and compare them to the Department's coverage decisions and treatment guidelines.  The utilization review provider makes a recommendation to the Department about authorizing or denying a request. 

Closing Orders and Reopening a Claim.

If a worker's condition changes, the Department may reopen a closed claim if a worker submits an application within 7 years of the claim’s closure.  This option does not apply to permanent total disability cases.

Continued Treatment in Permanent Total Disability Cases.

For permanent total disability claims, covered treatment ends on the date of a lump sum settlement or when the worker is placed on a permanent pension.  However, the Supervisor of Industrial Insurance may authorize continued treatment when necessary to protect the worker’s life or for the administration of medical and therapeutic measures.

Worker’s Choice of Provider.

An employer must inform an injured worker that the worker has a right to seek medical treatment from a provider of the worker's choice.  An employer may not require or induce an injured worker to seek treatment from a specific provider or clinic.  The Department must investigate any allegation that an employer attempted to require or induce an injured worker to seek treatment from a specific provider or clinic.  A violation by a self-insured employer is a violation of the statutory duty of good faith and subjects the employer to penalties.  A violation by other employers subjects the employer to penalties for claim suppression.

If an injured worker is unable to find a provider in the medical provider network within 15 miles of the worker's home, the worker may provide notice to the Department or self-insured employer, and the Department or self-insured employer must provide a declaration certifying this fact within 7 days.  The worker may seek treatment from a nonnetwork provider, if the provider agrees to be paid according to the Department's fee schedule.

Coverage Decisions and Treatment Guidelines.

If a provider determines that the Department's coverage decisions, treatment guidelines, policies, or national guidelines are not medically appropriate, the provider may deviate from the decisions, policies, or guidelines.

Utilization Review.

Utilization review must be completed within 10 business days from the date the Department received a request for approval, or the treatment must be authorized.

Continued Treatment.

In addition to cases of permanent total disability, the Supervisor of Industrial Insurance may authorize continued treatment in cases of permanent partial disability when necessary to protect the worker's life or provide for the administration of medical and therapeutic measures.

Continued monitoring of cancer is covered at a frequency recommended by the worker's oncologist.

Closing Orders and Reopening a Claim.

Orders awarding permanent total disability compensation are added to the definition of "closing order," allowing permanent total disability compensation claims to be reopened, if a worker's condition changes.

Written Notice When Removing a Provider from the Medical Provider Network.

When the Department removes a provider from the medical provider network, it must be done in writing.  The provider may appeal to the Washington State Board of Industrial Insurance Appeals.