	Proposed WAC Sections and Titles	This proposed rule section is not exempt - Analysis is required	This proposed rule section is exempt. Provide RCW to support this exemption.
1.	WAC 296-20-01020, Health care provider network enrollment: Subsections (1) and (2)	☐	RCW 34.05.328 (5)(b)(iv) Housekeeping. Amendments clarify language without changing the substance or effect of the rule.
2.	WAC 296-20-01020, Health care provider network enrollment: Subsection (3)	X
3.	WAC 296-20-01020, Health care provider network enrollment: Subsection (4)	☐	RCW 34.05.328 (5)(c)(i) Procedural. Amendments align language with current agency procedure.
4.	WAC 296-20-01020, Health care provider network enrollment: Subsections (5) through (7)	X
5.	WAC 296-20-01030 Minimum health care provider network standards	X
6.	WAC 296-20-01040 Health care provider network continuing requirements: Section title	☐	RCW 34.05.328 (5)(b)(iv) Housekeeping. Amendments clarify language without changing the substance or effect of the rule.
7.	WAC 296-20-01040 Health care provider network continuing requirements: Subsections (3) through (5)	X
8.	WAC 296-20-01040 Health care provider network continuing requirements: Subsection (6)	☐	RCW 34.05.328 (5)(b)(iv) Housekeeping. Amendments clarify language without changing the substance or effect of the rule.
9.	WAC 296-20-01040 Health care provider network continuing requirements: Subsections (7) and (8)	X
10.	WAC 296-20-01050 Health care provider network further review and denial	X
11.	WAC 296-20-01080 Management of the provider network	X
12.	WAC 296-20-01100 Risk of harm	X
13.	WAC 296-20-015 Who may treat: Subsections (1) through (6)	X
14.	WAC 296-20-015 Who may treat: Subsection (7)	☐	RCW 34.05.328 (5)(c)(i) Procedural. Amendments align language with current agency procedure.

(1) The department or its delegated entity will review the provider's application, supporting documents, and any other information requested or accessed by the department that is relevant to verifying the provider's application, clinical experience or ability to meet or maintain provider network membership requirements.

(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))30 days of the date of the notification from the department. Incomplete applications will be considered withdrawn within ((forty-five))45 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 and affirmatively respond to any department requests for 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))within the designated time frame, as specified 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))the time frames specified by the department.

(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))are eligible 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 subsection (7) of this section))Upon approval into the health care provider network, the provider may receive payment for ongoing care on or after the date a complete application was submitted to the department.

(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))(approved for payment) while their application is being processed, after 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))60 calendar days. Providers who have previously participated in the network are not eligible for provisional enrollment.

The department will deny an application, suspend membership, or terminate membership if a provider does not meet ((minimum)) health care provider network standards. To be eligible for enrollment and ((participation))continued membership in the health care provider network, a provider must meet and maintain the following ((minimum)) health care provider network standards:

(1) The provider must submit an accurate and complete provider application, including ((any))all required supporting documentation and sign without modification, a provider agreement with the department.

(2) The provider must respond to requests for information to verify provider adherence to health care provider network membership requirements within the time frame specified by the department.

(3) The provider must ((have))maintain current professional liability coverage, individually or as a member of a group, through a commercial carrier or provide documentation of self-insurance.

(a) Professional liability coverage must be at least in the amounts of ((one million dollars))$1,000,000 per occurrence and ((three million dollars))$3,000,000 annual aggregate((; or in the amounts otherwise published by the department for the provider type's scope of practice, after notice and opportunity for comment)).

(b) Providers in a group practice who are self-insured for professional liability coverage must provide evidence that liabilities in amounts at least equivalent to liability limits in (a) of this subsection are booked on audited financial statements in accordance with generally accepted accounting standards.

(((3)))(4) The provider must not have had or currently have clinical admitting and management privileges denied, limited or terminated ((for quality of care issues)).

(((4)))(5) The provider must not be or have been excluded, expelled, terminated, or suspended from any federally or state funded health care programs including, but not limited to, medicare or medicaid programs ((based on cause or quality of care issues)).

(((5) The provider must not have made))(6) Any material misstatement or omission to the department concerning licensure, registration, certification, disciplinary history or any other ((material matter covered in the application or credentialing materials))matter will result in denial of application or termination of health care provider network membership, regardless of when the misstatement or omission occurs.

(((6)))(7) The provider must not have been convicted of a felony or pled guilty or no contest to a felony for a crime including, but not limited to, health care fraud, ((patient abuse and))any crimes against a person, or the unlawful manufacture, distribution, prescription or dispensing of controlled substances.

The department may grant an exception for a felony that the provider has had expunged (vacated criminal conviction) from the provider's record.

(((7)))(8) The provider must be currently licensed, certified, accredited or registered according to Washington state laws and rules or in any other jurisdiction where the applicant treats injured workers and be free of any formal or informal action by any licensing entity.

(a) The license, registration or certification must be free of any restriction((s)), limitation((s)), or condition((s)) relating to the provider's clinical practice. Any changes to the license, registration or certification must be reported to the department within 10 days.

(b) The provider must not have surrendered, voluntarily or involuntarily ((his or her)), their professional state license in any state while under investigation, pending licensure proceedings or action, or due to findings by the state resulting from ((the provider's acts, omissions, or conduct))any act, omission or conduct of the provider.

(c) The department may grant an exception for any restriction, limitation, or condition deemed by the department to be minor ((or clerical)) in nature or ((for a case where))when the restriction, limitation, or condition has been removed.

(((8)))(9) The provider must have a current Drug Enforcement Administration (DEA) registration, if applicable to the provider's scope of licensure.

(a) The DEA registration must be free of any restriction((s)), limitation((s)), or condition((s)) related to the ((provider's acts))act, omission((s)), or conduct of the provider. Any changes to the DEA registration must be reported to the department within 10 days.

(b) The provider must not have surrendered, voluntarily or involuntarily ((his or her))their DEA registration in any state while under investigation or due to findings resulting from ((the provider's acts))any act, omission((s)), or conduct of the provider.

(c) The department may grant an exception for any restriction, limitation, or condition deemed by the department to be minor ((or clerical)) in nature or ((for a case where))in cases which did not result in severe harm to patients, and for which the restriction, limitation or condition has been removed.

To continue to provide care for workers and be paid for those services, a provider must:

(1) Provide services without unlawful discrimination;

(2) Provide services and bill according to federal and state laws and rules, department rules, policies, and billing instructions;

(3) ((Maintain material compliance with minimum))Comply with health care provider network membership standards, department credentialing and ((recredentialing))ongoing monitoring standards, and, when medically appropriate, follow the department's evidence-based coverage decisions and treatment guidelines, policies((;)), and must, when medically appropriate, follow other national treatment guidelines appropriate for their patient;

(4) ((Inform the department or an applicable delegated credentialing entity of any material))Notify the department of any changes to the provider's contact information, professional status, application, or provider agreement within ((fourteen))14 calendar days including, but not limited to, changes in:

(a) Ownership or business name;

(b) Address or telephone number;

(d) Licensing status, such as any informal ((or))action or disposition formal disciplinary order, decision, disciplinary action or other action(s), including any criminal action, in any state;

(e) Provider clinical privileges;

(f) ((Malpractice claims or))Any practice limitation or condition placed by a physician health program, such as the Washington physicians health program (WPHP), or health care facility;

(g) Any change in professional liability coverage resulting from malpractice claims;

(h) Compliance with provider health monitoring organizations, such as the Washington physicians health program (WPHP);

(i) Business license, registration, or certification;

(j) Any other material matter covered in the application or condition contained in provider agreement;

(5) ((Retain))Failure to notify the department of any change means the provider is noncompliant with the health care provider network membership standards regardless of when the omission occurs;

(6) Maintain a current professional state license, registration, certification and/or applicable business license for the service being provided, and update the department of all changes;

(((6)))(7) Comply with ((department recredentialing process))the department's ongoing monitoring process, which is defined as review by the department of provider's continued adherence to the provider agreement, health care provider network standards, and other requirements of Titles 51 RCW and 296 WAC; and

(((7)))(8) Comply with ((the))any department instructions ((contained in a department action))or requests, including documentation of compliance and participation in mentoring, monitoring, or restrictions.

(1) The department may ((further)) review a ((complete provider application))provider's membership in the health care provider network based on information ((within the application or credentialing information obtained from other sources))obtained by the department.

(2) ((For complete applications requiring further review))In reviewing both applications and ongoing health care provider network membership, the department's medical director or designee has the authority to approve or deny an applicant, and suspend, or terminate a provider consistent with department rules and policies, and may seek information, advice, expertise, and consultation or recommendations ((on applications)) from:

(a) Peer or clinical review ((individuals))professionals or entities;

(b) ((The industrial insurance medical or chiropractic advisory committee (including a subcommittee)))Other state health program or licensing bodies;

(d) A department appointed credentialing committee.

(3) Suspension is a department action rendering a provider temporarily unable to treat workers.

(4) The department may deny a provider application during credentialing ((or recredentialing based on the provider's professional qualifications and practice history including)), and suspend, or terminate ongoing health care provider network membership at any time based on, but not limited to:

(a) ((The provider fails))Failure to meet ((minimum)) health care provider network standards;

(b) ((The provider has been disciplined based on an allegation of sexual misconduct or admitted to sexual misconduct))Discipline due to an allegation, admission, or conviction of sexual misconduct or harm against a person;

(c) ((The provider is noncompliant with the department of health's or other state health care agency's stipulation to informal disposition (STID), agreed order, or similar licensed restriction))Any temporary or permanent probation, suspension, revocation, stipulation to informal disposition (or other informal licensing or disciplinary action), agreed order, or limitation, with or without conditions, on a practitioner's license to practice by any court, board, administrative agency, hospital, or health care facility;

(d) ((The provider has))Any pending formal or informal statement of charges or notice of proposed disciplinary action or equivalent from any state or governmental ((professional disciplinary board at the time of application or recredentialing))entity;

(e) ((The provider is excluded, expelled, terminated, or suspended))Exclusion, expulsion, termination, or suspension by medicare, medicaid or any other state or federally funded health care program;

(f) ((The provider has a))Denial, suspension, or termination of participation or privileges by any health care institution, insurance plan, facility, or clinic; except where such decision was solely related to broad network or business management changes, instead of an individual determination;

(g) ((The provider has surrendered, voluntarily or involuntarily, his or her hospital privileges in any state while under investigation or due to findings resulting from the provider's acts, omissions))Hospital privileges that are or have been surrendered, voluntarily or involuntarily, in any state while under investigation or when proceedings are pending, resulting from any act, omission, or conduct;

(h) The ((provider performs))performance of invasive or surgical procedures without:

(i) Clinical admitting and management privileges((,)) in good standing; or

(ii) An inpatient coverage plan with participating practitioner(s), hospitalists, or inpatient service teams for the purpose of admitting patients. Any inpatient coverage plan must be specified by the provider and found to be acceptable by the department.

(i) ((The provider has))Significant malpractice ((claims))claim(s) or professional liability ((claims())claim(s). Significance is based on materiality to current practice, severity, recency, frequency, or repetition(()));

(j) The provider is or has been ((materially)) noncompliant with the department's rules, administrative and billing ((policies, evidence-based coverage decisions and))requirements, or when medically appropriate, the department's evidence-based coverage decisions, treatment guidelines, and policies, and, when medically appropriate, other national treatment guidelines appropriate for their patient (((based on severity, recency, frequency, repetition, or any mitigating circumstances)));

(k) ((The provider was or is found to be involved))Provider involvement in acts of dishonesty, fraud, deceit or misrepresentation ((that, in the department's determination, could relate to or impact the provider's professional conduct or the safety or welfare of injured or ill workers));

(l) ((The provider was or is found to have committed))Provider negligence, incompetence, inadequate or inappropriate treatment or lack of appropriate follow-up treatment which results in ((injury))harm to a worker or creates an unreasonable risk ((that a worker may be harmed (based on severity, recency, frequency, repetition, or any mitigating circumstances)))of harm;

(m) ((The provider uses))Provider use of health care providers or health care staff who are unlicensed to practice or who provide health care services outside their recognized scope of practice or the standard of practice in Washington or in any other state the provider practices in;

(n) ((The provider with a))Provider history of alcohol or chemical dependency ((fails))and failure to furnish documentation demonstrating ((that the provider complied or is complying with all))compliance with conditions, limitations, or restrictions ((to))on the provider's ((practice))license, and that the provider has received or is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice;

(o) ((The provider has an))A formal or informal licensure action((s)), condition((s)), agreement((s)), or order((s))including, but not limited to, a stipulation to informal disposition (STID) or agreed order;

(p) ((The provider has))A history of probation, suspension, termination, revocation or a surrendered professional license, certification, accreditation, or registration listed in the National Provider Data Bank((/Healthcare Integrity and Protection Data Bank)) or any like entity; or by a nationally recognized specialty board; or by a state authority in any jurisdiction including, but not limited to, the Washington state department of health, when such charges involve conduct or behavior as defined under chapter 18.130 RCW, Uniform Disciplinary Act;

(q) ((The provider engaged in))Billing fraud or abuse or ((has)) a history of other significant billing irregularities;

(r) ((There are material))Complaints or allegations demonstrating a pattern of behavior(s) or misrepresentations including, but not limited to, incidents, misconduct, or inappropriate prescribing of controlled substances (((based on severity, recency, frequency, repetition, or any mitigating circumstances)));

(s) The provider has a criminal history which includes, but is not limited to, any criminal charge((s, criminal investigations)), conviction((s)), no contest plea((s and)), plea agreement, or guilty plea((s)); or

(t) ((A finding of risk of harm pursuant to WAC 296-20-01100))Any act that the department determines is contrary to the health and safety of injured workers.

(((4)))(5) The department and self-insured employers will not pay for any care provided to injured workers, other than an initial or emergency room visit, by a provider whose application has been denied.

(6) The department and self-insured employers will continue to pay for any services provided to injured workers by a provider whose health care provider network membership has been terminated and the decision appealed up to the date of the final board of industrial insurance appeals (BIIA) decision upholding department action.

(1) Appropriate action(s) by the department to monitor quality of care and ((assure))ensure efficient management of the provider network may include, but are not limited to:

(a) Monitoring the provider;

(b) Mentoring the provider;

(d) Restricting payment for services rendered by the provider;

(((d)))(e) Suspending the provider from the health care provider network; or

(((e)))(f) Removing the provider from the health care provider network.

(2) The department ((must first notify the provider, and)) may take action in any order or combination, depending on the severity of the issue or risk of harm.

(3) ((For risk of harm issues, where imminent or actual harm is not life-threatening or substantially disabling, the department may provide an opportunity for the provider to remediate through education or other less severe actions first. Where the department action includes suspension or removal from the network for risk of harm issues, the department may also request expedited hearing and immediate suspension of authority to provide services under RCW 51.52.075.

(4))) In taking appropriate action ((for risk of harm issues)), the department will take into account unique mitigating circumstances related to the clinical severity and complexity of the providers' patient population. Unique mitigating circumstances could include practice at a care facility recognized for its receipt of particularly severe cases, such as catastrophic injuries. Duration of disability and/or chronic pain shall not, in and of themselves, be considered uniquely mitigating.

((The department may not take action against a provider for risk of harm, if the harm was related to an isolated instance of health care service delivery that was conducted within coverage policies and treatment guidelines established by the department or other evidence-based coverage decisions made by the Washington state health technology committee, or the prescription drug program and appropriate to the patient's specific circumstances.

(5)))(4) The department may also terminate ((a))health care provider network ((agreement))membership for cause based on the provider's professional qualifications, billing, and practice history including, but not limited to, the following:

(a) The provider fails to maintain ((the minimum)) health care provider network standards per WAC 296-20-01030;

(b) The provider fails to comply with health care provider network continuing requirements per WAC 296-20-01040;

(c) The provider engages in action or inaction for which the department may deny ((an application))ongoing participation;

(d) The provider violates the terms of the provider agreement((; or

(e) A finding of risk of harm, pursuant to WAC 296-20-01100 including, but not limited to, prescribing drug therapy in an unsafe manner and/or failure to identify substance abuse/addiction or failure to refer the patient for substance abuse treatment once abuse/addiction is identified.

(6) The department will notify the provider of agreement termination according to the terms of the agreement, identify the reason for agreement termination, and include an effective date of termination. If a provider agreement is terminated for cause, the department or self-insured employer will pay for authorized services provided only up to the date specified in the notice)), which is considered a contract.

(5) The department may administratively remove a provider from the health care provider network when there has been no billing activity by a provider for 18 months.

(6) Department actions are effective upon receipt of notice unless a provider submits a request for reconsideration to the department or files an appeal with the board of industrial insurance appeals (BIIA) within 60 days of notice per chapter 51.52 RCW.

(1) ((It is the intent of))The department may, through authority granted by RCW 51.36.010 to protect workers from the risk of physical or psychiatric harm by identifying, and taking appropriate action, including removal of providers from the ((statewide))health care provider network, when((:

(a) There is harm; and

(b) There is a pattern(s) of low quality care; and

(2) ((It is not the intent of the department to remove or otherwise take action when providers are practicing within department policies and guidelines, or within best practices established or developed by the department, or established in collaboration with its industrial insurance medical and chiropractic advisory committees.

(3) The department may permanently remove a provider from the statewide network or take other appropriate action when that provider's treatment of injured workers exhibits a ))pattern or patterns of conduct of low quality care that exposes patients to a risk of physical or psychiatric harm or death.

(4)))Harm is defined as (intended or unintended) physical or psychiatric injury resulting from((, or contributed to, by)) health care services ((that))which results in the need for additional monitoring, treatment, or hospitalization, or that worsens the condition(s), increases disability, or causes death. Harm can include((s)) increased, chronic, or prolonged pain or decreased function occurring from treatment of an industrial injury or occupational disease.

(((5)))(3)Pattern ((or patterns)) of low quality care is((/are)) defined as including one or more of the following:

(a) ((For health services where the department can calculate normative data on frequency, a provider's cases are in the lowest decile (at or below the tenth percentile); or

(b) For health services where the department cannot calculate normative data on frequency, at least twenty percent of requested or conducted services meet the definition of low quality care; or

(c) For health services where department data or scientific literature has reported expected rates of adverse events, a provider's adverse event rates are at least twenty percent above the expected rate; or

(d) A review of a random sample of the provider's cases demonstrates that at least twenty percent of cases do not meet peer matched criteria for acceptable quality; or

(e) Two or more deaths or life-threatening events; or

(f)))A history of substantiated quality-of-care complaints; or

(b) Care that results in death or threat to life of disability; or

(c) Peer review findings of noncompliance with, when medically appropriate, the department's evidence-based coverage decisions and treatment guidelines, or, when medically appropriate, other national treatment guidelines appropriate for their patient; or

(d) Provider behavior(s) and/or ((practices that result))practice(s) resulting in revocation or limitation of hospital privileges, or formal or informal professional licensure ((sanctions.

(6) Low quality care in the statewide workers' compensation network is defined as treatments or treatment regimens:

(a) That have not been shown to be safe or effective or for which it has been shown that the risks of harm exceed the benefits that can reasonably be expected, based on available peer-reviewed scientific studies; or

(b) That uses))actions; or

(e) Use of diagnostic tests or treatment interventions not in compliance with the department's payment policies, the department's applicable utilization review criteria, or ((the department's guidelines))not following, when medically appropriate the department's evidence-based coverage decisions and treatment guidelines or national treatment guidelines; or

(((c) That includes))(f) Repeated unsuccessful surgical or other invasive procedures; or

(((d) That is))(g) Providing care outside the provider's scope of practice or training; or

(((e)))(h) Care that results in the revocation or limitation of hospital privileges or in formal or informal professional licensure ((sanctions))actions; or

(((f) That fails))(i) Failure to include or deliver appropriate and timely health care services as identified in available department ((guidelines or)) policies, including inadequate documentation or attention to conditions that may hinder recovery from procedures such as chronic opioid use, dependence, or opioid use disorder, or failure to document ill-effects of prior failed procedures; or

(((g) That includes))(j) Repetitive provision of care that is not curative or rehabilitative as required in the definition of proper and necessary per WAC 296-20-01002 ((for extended periods that does not contribute to recovery, return to work, or claim resolution)); or

(((h) That includes))(k) Repeated testing including, but not limited to, routine use of a diagnostic test or procedure by either the provider prescribing or the provider performing the test, when any of the following apply:

(i) The test(s) have been demonstrated to be unsafe or of poor quality; or

(ii) ((High quality, peer-reviewed scientific studies do not show that the test has the technical capacity (reliable and valid) and accuracy to result in successful clinical outcomes for their intended use (utility)))Lack of peer-reviewed studies demonstrating the medical efficacy of test to accurately diagnose conditions and improve health outcomes under ideal, controlled conditions; or

(iii) The test is conducted or interpreted in a manner inconsistent with ((high quality evidence-based clinical practice guidelines)), when medically appropriate, the department's evidence-based coverage decisions and treatment guidelines, policies or, when medically appropriate, other national treatment guidelines; or

(iv) The test is likely to lead to treatment ((that does not meet department guidelines or policies or)) is otherwise harmful.

To treat workers under the Industrial Insurance Act, a health care provider must qualify as an approved provider under the department's rules. The department must approve the health care provider before the health care provider is eligible for payment for services.

(1) ((A))All providers must:

(a) Apply, and ((be))if enrolled, maintain membership in the health care provider network per WAC 296-20-01010; or

(b) ((If the))Apply and obtain a provider account number per WAC 296-20-12401 when the health care provider network scope in WAC 296-20-01010 is not applicable((, apply and obtain a provider account number per WAC 296-20-12401)).

(2) If the provider or service is within the scope of the provider network under WAC 296-20-01010:

(a) A nonnetwork provider is not authorized to treat and will not be reimbursed by the department or self-insurer for services other than the initial office or emergency room visit. The following services are considered part of the initial office or emergency room visit:

(i) Services that are bundled with those performed during the initial visit where no additional payment is due (as defined in WAC 296-20-01002); and

(ii) In the case of an injured worker directly hospitalized from an initial emergency room visit, all services related to the industrial injury or illness provided through the hospital discharge.

(b) A nonnetwork provider must refer injured workers to a network provider((s)) when additional treatment is needed((,)) and must provide timely copies of medical records to the other provider and the department or self-insurer.

(3) ((Para-professionals))Medical staff, who are not independently licensed, must practice under the direct supervision of a licensed health care professional whose scope of practice and specialty training includes the service provided by the ((para-professional))medical staff. The department may deny direct reimbursement to the para-professional for services rendered((,)) and may instead directly reimburse the licensed ((and)), supervising, or collaborating health care professional for covered services. Payment rules for para-professionals may be determined by department policy.

(4) Procedures and evaluations requiring specialized skills and knowledge will be limited to board certified or board qualified physicians, or osteopathic physicians as specified by the American Medical Association or the American Osteopathic Association.

(5) The department as a trustee of the medical aid fund has a duty to supervise provision of proper and necessary medical care that is delivered promptly, efficiently, and economically. The department can deny, revoke, suspend, limit, or impose conditions on a health care provider's authorization to treat workers under the Industrial Insurance Act. Reasons for denying issuance of a provider number, removing a provider from the health care provider network, or imposing any of the above restrictions include, but are not limited to, the following:

(a) Incompetence or negligence, which results in ((injury to a worker))harm or which creates an unreasonable risk ((that a worker may be harmed))of harm.

(b) The possession, use, prescription for use, or distribution of controlled substances, legend drugs, alcohol, or other addictive, habituating, or dependency-inducing substances ((in any way other than for therapeutic))contrary to medical and legal purposes.

(c) Any temporary or permanent probation, suspension, revocation, agreed order, stipulation to informal disposition, or type of limitation ((of)), with or without conditions, on a practitioner's license to practice by any court, board, ((or)) administrative agency, hospital, or health facility.

(d) The commission of any act involving moral turpitude, dishonesty, or corruption relating to the practice of the provider's profession. The act need not constitute a crime. If a conviction or finding of such an act is reached by a court or other tribunal pursuant to plea, hearing, or trial, a certified copy of the conviction or finding is conclusive evidence of the violation.

(e) The failure to comply with the department's orders, rules, or ((policies)), when medically appropriate, the department's evidence-based coverage decisions and treatment guidelines, policies, and when medically appropriate, other national treatment guidelines.

(f) The failure, neglect, or refusal to:

(i) Provide records requested by the department pursuant to a health care services review or an audit.

(ii) Submit complete, adequate, legible, and detailed reports or additional reports requested or required by the department regarding the treatment and condition of a worker.

(g) The submission of or collusion ((in the submission of))to submit a false or misleading report((s)) or bill((s)) to any government agency.

(h) Billing a worker for:

(i) Treatment of an industrial condition for which the department has accepted responsibility; or

(ii) The difference between the amount paid by the department under the maximum allowable fee set forth in these rules and any other charge.

(i) ((Repeated))Failure to notify the department immediately and prior to ((burial))disposition of remains in any death, where the cause of the death is not definitely known and possibly related to:

(i) An industrial injury ((or));

(ii) Occupational disease; or

(iii) Treatment related to an industrial injury of occupational disease.

(j) ((Repeated))Failure to recognize emotional and social factors impeding recovery of a worker who is being treated under the Industrial Insurance Act.

(k) ((Repeated))Unreasonable refusal to comply with the recommendations of board certified or qualified specialists who have examined a worker.

(l) ((Repeated))Use of:

(i) Treatment of controversial or experimental nature;

(ii) Contraindicated or hazardous treatment; or

(iii) Treatment past stabilization of the industrial ((condition or))injury or occupational disease after maximum curative or rehabilitative improvement has been obtained.

(m) Declaration of mental incompetency by a court or other tribunal.

(n) Failure to comply with the applicable code of professional conduct or ethics.

(o) Failure to inform the department of any disciplinary or other action (formal or informal) issued by ((order or formal letter taken against the provider's license to practice))a licensing body or entity or health care facility.

(p) The finding of any peer group review body of reason to take action against the provider's practice privileges.

(q) Misrepresentation or omission of any material information in the application for authorization to treat workers, chapter 51.04 RCW.

(r) Acceptance of a kickback, bribe, or rebate violation contained in RCW 51.48.280.

(6) If the department finds reason to take corrective action, the department may ((also order))do one or more of the following:

(a) Recoupment of payments made to the provider, including interest, chapter 51.04 RCW;

(b) Denial or reduction of payment;

(c) Assessment of penalties for each action that falls within the scope of subsection (5)(a) through (((q)))(r) of this section, chapter 51.48 RCW;

(d) Placement of the provider on a prepayment review status requiring the submission of supporting documents prior to payment;

(e) ((Requirement to satisfactorily complete))Require satisfactory completion of remedial corrective action including, but not limited to, education courses and/or programs; and

(f) Imposition of other appropriate restrictions or conditions on the provider's ((privilege))right to be reimbursed for treating workers under the Industrial Insurance Act.

(g) Suspension of a provider agreement rendering the provider temporarily unable to treat workers due to a pending civil, criminal, or licensure action. Once the matter has been finally decided, the department will reevaluate the suspension.

(7) The department shall forward a copy of any corrective action taken against a provider to the applicable disciplinary authority when the action becomes final.