PREPROPOSAL STATEMENT OF INQUIRY
LABOR AND INDUSTRIES
Subject of Possible Rule Making: To amend the definition of "proper and necessary" in WAC 296-20-01002 and to amend as necessary the criteria for making medical coverage decisions in WAC 296-20-02704.
Statutes Authorizing the Agency to Adopt Rules on this Subject: RCW 51.04.020, 41.05.013.
Reasons Why Rules on this Subject may be Needed and What They Might Accomplish: ESHB 1299, chapter 276, Laws of 2003, directed the state agencies involved in state purchased health care programs, to the extent possible, to develop a common definition of medical necessity. A common definition may reduce administrative burden for providers. An expanded definition of "proper and necessary" and "scientific evidence" will make it clearer how this agency makes coverage decisions and makes a determination of proper and necessary.
Other Federal and State Agencies that Regulate this Subject and the Process Coordinating the Rule with These Agencies: Of the state agencies that purchase health care services, the Department of Social and Health Services (DSHS) and the Health Care Authority (HCA) are also moving forward to amend their definition of "medical necessity." These state agencies and L&I are starting with model contractual language for "medical necessity" developed out of Stanford University. L&I is looking for language from this Stanford model that is compatible with Title 51 RCW and may expand further when necessary to clarify the defined terms.
Process for Developing New Rule: The agency will develop this rule in coordination with the following major stakeholder groups; Workers' Compensation Advisory Committee, Department of Social and Health Services, and Health Care Authority.
Interested parties can participate in the decision to adopt the new rule and formulation of the proposed rule before publication by contacting Jami Lifka, Department of Labor and Industries, Office of the Medical Director, P.O. Box 44321, Olympia, WA 98504-4321, phone (360) 902-4941, or fax (360) 902-6315.
November 12, 2003