All services rendered must be in accordance with the medical
aid rules, fee schedules, and department policy. The department or self-insurer
may reject bills for services rendered in violation of these rules. Workers may
not be billed for services rendered in violation of these rules.
(1) Bills must be itemized on department or
self-insurer forms or other forms which have been approved by the department or
self-insurer. Bills may also be transmitted electronically using department
file format specifications. Providers using any of the electronic transfer
options must follow department instructions for electronic billing. Physicians,
osteopaths, advanced registered nurse practitioners, chiropractors,
naturopaths, podiatrists, psychologists, and registered physical therapists use
the current national standard Health Insurance Claim Form (as defined by the
National Uniform Claim Committee) with the bar code placed 2/10 of an inch from
the top and 1 1/2 inches from the left side of the form. Hospitals use the
current National Uniform Billing Form (as defined by the National Uniform
Billing Committee) for institution services and the current national standard
Health Insurance Claim Form (as defined by the National Uniform Claim
Committee) with the bar code placed 2/10 of an inch from the top and 1 1/2
inches from the left side of the form for professional services. Hospitals
should refer to chapter
296-23A WAC for billing rules pertaining to
institution, or facilities, charges. Pharmacies use the department's statement
for pharmacy services. Dentists, equipment suppliers, transportation services,
vocational services, and massage therapists use the department's statement for
miscellaneous services. When billing the department for home health services,
providers should use the "statement for home nursing services." Providers may
obtain billing forms from the department's local service locations.
(2) Bills must specify the date and type of
service, the appropriate procedure code, the condition treated, and the charges
for each service.
(3) Bills
submitted to the department must be completed to include the following:
(a) Worker's name and address;
(b) Worker's claim number;
(c) Date of injury;
(d) Referring doctor's name and L & I
provider account number;
(e) Area
of body treated, including the current federally adopted ICD-CM code(s),
identification of right or left, as appropriate;
(f) Dates of service;
(g) Place of service;
(h) Type of service;
(i) Appropriate procedure code, hospital
revenue code, or national drug code;
(j) Description of service;
(k) Charge;
(l) Units of service;
(m) Tooth number(s);
(n) Total bill charge;
(o) The name and address of the practitioner
rendering the services and the provider account number assigned by the
department;
(p) Date of
billing;
(q) Submission of
supporting documentation required under subsection (6) of this
section.
(4)
Responsibility for the completeness and accuracy of the description of services
and charges billed rests with the practitioner rendering the service,
regardless of who actually completes the bill form;
(5) Vendors are urged to bill on a monthly
basis. Bills must be received within one year of the date of service to be
considered for payment.
(6) The
following supporting documentation is required when billing for services:
(a) Laboratory and pathology
reports;
(b) X-ray
findings;
(c) Operative
reports;
(d) Office
notes;
(e) Consultation
reports;
(f) Special diagnostic
study reports;
(g) For BR
procedures - See chapter
296-20 WAC for requirements; and
(h) Special or closing exam
reports.
(7) The claim
number must be placed on each bill and on each page of reports and other
correspondence in the upper right-hand corner.
(8) The following considerations apply to
rebills.
(a) If you do not receive payment or
notification from the department within one hundred twenty days, services may
be rebilled.
(b) Rebills must be
submitted for services denied if a claim is closed or rejected and subsequently
reopened or allowed. In these instances, the rebills must be received within
one year of the date the final order is issued which subsequently reopens or
allows the claim.
(c) Rebills
should be identical to the original bill: Same charges, codes, and billing
date.
(d) In cases where vendors
rebill, please indicate "REBILL" on the bill.
(9) The department or self-insurer will
adjust payment of charges when appropriate. The department or self-insurer must
provide the health care provider or supplier with a written explanation as to
why a billing or line item of a bill was adjusted at the time the adjustment is
made. A written explanation is not required if the adjustment was made solely
to conform with the maximum allowable fees as set by the department. Any
inquiries regarding adjustment of charges must be received in the required
format within ninety days from the date of payment to be considered. Refer to
the medical aid rules for additional information.
