LABOR AND INDUSTRIES
Preproposal statement of inquiry was filed as WSR 12-23-074.
Title of Rule and Other Identifying Information: Chapter 296-15 WAC, Workers' compensation self-insurance rules and regulations, SSB 5801 (chapter 6, Laws of 2011), as it amends RCW 51.36.010, directs the department of labor and industries (L&I) to establish a statewide health care provider network to treat injured and ill workers and to expand the Centers for Occupational Health and Education in the workers' compensation system. Rules are necessary to implement these changes. Self-insured employers are included within the network provisions in SSB 5801. This rule-making process is to clarify the self-insured employers' requirements.
Hearing Location(s): L&I, Tumwater Building, Room S117, 7273 Linderson Way S.W., Tumwater, WA 98501, on February 27, 2013, at 12:30 p.m.
Date of Intended Adoption: April 9, 2013.
Submit Written Comments to: Jami Lifka, P.O. Box 44321, Olympia, WA 98501, or e-mail Jami.Lifka@Lni.wa.gov, or fax (360) 902-6315, and are received no later than 5 p.m., February 27, 2013.
Assistance for Persons with Disabilities: Contact office of information and assistance by February 1, 2013,
TTY (360) 902-5797 or (360) 902-4941.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: An amendment to WAC 296-15-330 is being proposed to ensure that department rules for self-insured employers related to medical care are consistent with and include reference to the statewide health care provider network established in SSB 5801.
The subject of this fourth rule making is to specify the requirements of self-insured employers to ensure their workers receive the information necessary to access care within the health care provider network.
Statutory Authority for Adoption: RCW 51.36.010, 51.04.020, and 51.04.030.
Statute Being Implemented: RCW 51.36.010.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Governor Gregoire, 2011 legislators, the governor's interim workgroup made up of representatives of state fund and self-insured businesses and workers, and L&I, private, public and governmental.
Name of Agency Personnel Responsible for Drafting: Natalee Fillinger, Program Manager Self-Insurance, (360) 902-6907; Implementation: Leah Hole-Curry, Medical Administrator, Office of the Medical Director, (360) 902-4996; and Enforcement: Vickie Kennedy, Assistant Director, Insurance Services, (360) 902-4997.
No small business economic impact statement has been prepared under chapter 19.85 RCW. This rule making applies only to self-insured employers. The department did not prepare a small business economic impact statement because it determined that the proposed rules will not have a disproportionate impact on small businesses.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained 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.
January 22, 2013
AMENDATORY SECTION(Amending WSR 06-06-066, filed 2/28/06, effective 4/1/06)
WAC 296-15-330 Authorization of medical care. What are the requirements for authorization of medical care? Every self-insurer must:
(1) Authorize treatment and pay bills in accordance with Title 51 RCW and the medical aid rules and fee schedules of the state of Washington.
(2) Provide a written explanation of benefits (EOB) to the provider, with a copy to the worker if requested, for each bill adjustment. A written explanation is not required if the adjustment was made solely to conform to the maximum allowable fees as set by the department.
(3) Establish procedures to ensure prompt responses to inquiries regarding authorization decisions and bill adjustments.
(4) Comply with the requirements of the health care provider network. This includes:
(a) Utilizing only those providers approved for the provider network, except when the provider specialty or geographic location is not yet covered by the network;
(b) Providing information to workers about the requirement for providers to be enrolled in the network in order to treat injured workers and information on how a worker can find network providers. This information must be included in publications used by self-insurers to comply with WAC 296-15-400 (2)(a);
(c) Ensuring, when applicable, that only network providers are paid for care after the initial office or emergency room visit; and
(d) Promptly assisting workers who are being treated by a nonnetwork provider to transfer their care to a network provider of their choice; including, at a minimum, notification to the worker within forty-five days of receipt of the first bill from a nonnetwork provider that the provider will not be paid for treatment beyond the initial visit on the claim and information about how to find network providers.
[Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. 06-06-066, § 296-15-330, filed 2/28/06, effective 4/1/06.]