491-05-030 - What is required for payment of medical services and materials?

491-05-030. What is required for payment of medical services and materials?

All medical services must be provided in accordance with the Washington State Department of Labor and Industry's medical aid rules, fee schedules, and these rules and any State Board policy, including but not limited to the Pain Management Policy. The State Board and/ or Local Boards may reject bills for services rendered in violation of these rules or policies. Participants may not be billed for services rendered in violation of these rules.

(1) Practitioners must use the current national standard Health Insurance Claim Form (as defined by the National Uniform Claim Committee). Hospitals must 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). All other Providers must contact the State Board for guidance on proper billing.

(2) Prior to submission to the State Board, all bills must first be submitted to the Local Board of the Participant's Municipality for processing.

(3) All Providers seeking payment must complete the most recent versions of the following forms, and be assigned a State Wide Vendor Number by the Office of Financial Management:

a.Statewide Payee Registration Washington State; and

b.Request for Taxpayer Identification Number and Certification (I-9).

(4) Bills must specify the date and type of service, the appropriate procedure code, the condition treated, and the charges for each service.

(5) Bills submitted to the Local Board must be completed to include the following:

a.Participant's name and address;

b.Participant's date of birth;

c.Date of injury;

d.Name of Participant's department;

e.Referring doctor's name;

f.Area of body treated, including ICD-9-CM code(s), identification of right or left, as appropriate;

g.Date(s) of service;

h.Place of service;

i.Type of service;

j.Appropriate procedure code, hospital revenue code, or national drug code;

k.Description of service;


m.Units of service;

n.Tooth number(s);

o.Total bill charge;

p.The name and address of the Practitioner rendering the services;

q.Tax ID number of the Practitioner or Provider wishing payment;

r.Date of billing; and s. Submission of supporting documentation required under subsection (7) of this section.

(6) Responsibility for the completeness and accuracy of the description of services and charges billed rests solely with the Practitioner rendering the service, regardless of who actually completes the bill form.

(7) Bills must be received by the State Board within two years of the date of service to be considered for payment. As such, Providers are urged to bill on a monthly basis.

(8) The following supporting documentation is required when billing for services, as applicable:

a.Laboratory and pathology reports:

b.X-ray findings;

c.Operative reports;

d.Office/chart notes;

e.Consultation reports;

f.Special diagnostic study reports;

g.Special or closing exam reports; and

h.All other reports as required by the Labor and Industry's medical aid rules, fee schedules, and State Board policy.

(9) The following considerations apply to rebills:

a.Providers that do not receive payment or notification from the State Board or a Local Board within one hundred twenty days, services may be rebilled.

b.Rebills must be submitted for services denied if a claim is rejected and subsequently allowed. In this instance, the rebills must be received within one year of the date of the State Board's decision to allow the claim.

c.Rebills should be identical to the original bill: Same charges, codes, and billing date.

d.In cases where a Provider rebills, the notation "REBILL" must be on the bill.

e.For Providers that submit a rebill due to a coding error, the rebill must contain the corrected coding, and be accompanied by documentation stating that it is a rebill, the date of service, and the original codes it was billed under.

(Adopted by WSR 15-01-063, Filed 12/11/2014, effective 1/11/2015)

The following state regulations pages link to this page.