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

     Purpose: SSB 5801 (chapter 6, Laws of 2011) directs the department of labor and industries (L&I) to establish a statewide health care provider network to treat injured and ill workers of employers insured with L&I and with self-insured employers. Rules are necessary to implement the changes required in SSB 5801.

     (1) The first rule-making phase adopted minimum standards for credentials of health care providers in the statewide health care provider network and to clarify what constitutes patterns of risk of harm or death that determines when L&I may remove a provider from the network or take other appropriate action.

     (2) The second rule-making phase amended existing rules to allow injured and ill workers to see a provider of their choice for the initial visit and to inform health care providers and workers when care must be transferred to a network provider.

     (3) This third rule making is necessary to address existing department rules that may conflict with the network implementation. Changes to the following WACs were adopted for consistency or clarification: WAC 296-20-01010, 296-20-01020, and 296-20-02705.

     Reasons Supporting Proposal: The third phase changes were adopted so that health care providers, state fund and self-insured employers, and injured and ill workers have a clear understanding of this new health care provider network and their rights and requirements under SSB 5801.

     Citation of Existing Rules Affected by this Order: Amending WAC 296-20-01010, 296-20-01020, and 296-20-02705.

     Statutory Authority for Adoption: RCW 51.36.010, 51.04.020, and 51.04.030.

      Adopted under notice filed as WSR 12-17-121 on August 21, 2012.

     Changes Other than Editing from Proposed to Adopted Version:

•	Clarifying change to WAC 296-20-01010.
•	Removing proposed amendments to WAC 296-20-03015 (see details in the CES).

     A final cost-benefit analysis is available by contacting Leah Hole-Curry, L&I, P.O. Box 44321, Olympia, WA 98504-4321, phone (360) 902-4996, fax (360) 902-6315, e-mail Leah.Hole-Curry@Lni.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 3, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 3, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 3, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, 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 3, Repealed 0.

     Date Adopted: November 13, 2012.

Judy Schurke

Director

OTS-4969.2

AMENDATORY SECTION(Amending WSR 12-02-058, filed 1/3/12, effective 2/3/12)

WAC 296-20-01010   Scope of health care provider network.   (1) The rules establish the development, enrollment, and oversight of a network of health care providers approved to treat injured workers. The health care provider network rules apply to care for workers covered by Washington state fund and self-insured employers.

     (2) As of January 1, 2013, the following types of health care providers (hereafter providers) must be enrolled in the network with an approved provider agreement to provide and be reimbursed for care to injured workers in Washington state beyond the initial office or emergency room visit:

     (a) Medical physicians and surgeons;

     (b) Osteopathic physicians and surgeons;

     (c) Chiropractic physicians;

     (d) Naturopathic physicians;

     (e) Podiatric physicians and surgeons;

     (f) Dentists;

     (g) Optometrists;

     (h) Advanced registered nurse practitioners; and

     (i) Physician assistants.

     (3) The requirement in subsection (2) of this section does not apply to providers who practice exclusively in acute care hospitals or within inpatient settings in the following specialties:

     (a) Pathologists;

     (b) Consulting radiologists working within a hospital radiology department;

     (c) Anesthesiologists or certified registered nurse anesthetists (CRNAs) except anesthesiologists and CRNAs with pain management practices in either hospital-based or ambulatory care settings;

     (d) Emergency room providers; or

     (e) Hospitalists.

     (4) The department may phase implementation of the network to ensure access within all geographic areas. The director of the department shall determine, at his/her discretion, whether to establish or expand the network, after consideration of at least the following:

     • The percent of injured workers statewide who have access to at least five primary care providers within fifteen miles, compared to a baseline established within the previous twelve months;

     • The percent of injured workers by county who have access to at least five primary care providers within fifteen miles, compared to a baseline established within the previous twelve months; and

     • The availability within the network of a broad variety of specialists necessary to treat injured workers.

     The department may expand the health care provider network scope to include additional providers not listed in subsection (2) of this section, listed in subsection (3) of this section, and to out-of-state providers. For providers outside the scope of the health care provider network rule, the department and self-insured employers may reimburse for treatment beyond the initial office or emergency room visit.

[Statutory Authority: RCW 51.36.010, 51.04.020, and 51.04.030. 12-02-058, § 296-20-01010, filed 1/3/12, effective 2/3/12.]

     (2) The department will notify providers of incomplete applications, including when credentialing information obtained from other sources materially varies from information on the provider application. The provider may submit a supplement to the application with corrections or supporting documents to explain discrepancies within thirty days of the date of the notification from the department. Incomplete applications will be considered withdrawn within forty-five days of notification.

     (3) The provider must produce adequate and timely information and timely attestation to support evaluation of the application. The provider must produce information and respond to department requests for information that will help resolve any questions regarding qualifications within the time frames specified in the application or by the department.

     (4) The department's medical director or designee is authorized to approve, deny, or further review complete applications consistent with department rules and policies. Providers will be notified in writing of their approval or denial, or that their application is under further review within a reasonable period of time.

     (5) Providers who meet the minimum provider network standards, have not been identified for further review, and are in compliance with department rules and policies, will be approved for enrollment into the network.

     (6) Enrollment of a provider is effective no earlier than the date of the approved provider application. The department and self-insured employers will not pay for care provided to workers prior to application approval, regardless of whether the application is later approved or denied, except as provided in ((this)) subsection (7) of this section.

     (7) The department and self-insured employers may pay a provider without an approved application only when:

     (a) The provider is outside the scope of the provider network per WAC 296-20-01010; or

     (b) The provider is provisionally enrolled by the department after it obtains:

     (i) Verification of a current, valid license to practice;

     (ii) Verification of the past five years of malpractice claims or settlements from the malpractice carrier or the results of the National Practitioner Data Bank (NPDB) or Healthcare Integrity and Protection Data Bank (HIPDB) query; and

     (iii) A current and signed application with attestation.

     (c) A provider may only be provisionally enrolled once and for no more than sixty calendar days. Providers who have previously participated in the network are not eligible for provisional enrollment.

[Statutory Authority: RCW 51.36.010, 51.04.020, and 51.04.030. 12-02-058, § 296-20-01020, filed 1/3/12, effective 2/3/12.]

     (2) The department may develop treatment or diagnostic guidelines to improve outcomes for workers receiving covered health services. As appropriate to the subject matter, the department may develop these guidelines in collaboration with the ((department's formal advisory)) following committees:

     • The industrial insurance medical advisory committee;

     • The industrial insurance chiropractic advisory committee.

     • The Washington state pharmacy and therapeutics committee.

     • The Washington state health technology assessment clinical committee.

     (3) In the process of implementing these guidelines, the department may find it necessary to make a formal medical coverage decision on one or more of the treatment or diagnostic options. The department, not the advisory committees, is responsible for implementing treatment guidelines and for making coverage decisions that result from such implementation.

     (4) Network providers are required to follow the department's evidence-based coverage decisions, treatment guidelines, and policies.

[Statutory Authority: 2007 c 282, RCW 51.04.02 [51.04.020], 51.04.030. 08-02-020, § 296-20-02705, filed 12/21/07, effective 1/21/08. Statutory Authority: RCW 51.04.020, 70.14.050. 04-08-040, § 296-20-02705, filed 3/30/04, effective 5/1/04. Statutory Authority: RCW 51.04.020 and 51.04.030. 00-01-037, § 296-20-02705, filed 12/7/99, effective 1/8/00.]