Initiating treatment and submitting a claim for benefits.
(1) Worker's responsibility: The worker must notify the provider when the worker has reason to believe his/her injury or illness is work related. If treatment beyond the initial office or emergency room visit is needed, the worker must seek treatment from a network provider.
(2) Provider's responsibility: The provider must notify the worker if he/she identifies an injury, illness, or condition which he/she has reason to believe is work related.
Once such determination is made by either the worker or the attending provider, a report of the injury or illness must be filed with the department or self-insurer.
Failure to comply with this responsibility can result in penalties as outlined in RCW 51.48.060
(3) Additional provider responsibilities: The provider must ascertain whether he/she is the first attending provider and give emergency treatment.
The first attending provider must immediately complete and forward a report of the injury or illness to the department or self-insurer and instruct and assist the injured worker in completing his/her portion of the report of the injury or illness. In filing a claim, the following information is necessary so there is no delay in adjudication of the claim or payment of compensation.
(a) Complete history of the work related accident or exposure.
(b) Complete listing of positive physical findings.
(c) Specific diagnosis with ICD-9-CM, or most current version as updated, code(s) and narrative definition relating to the injury.
(d) Type of treatment rendered.
(e) Known medical, emotional or social conditions which may influence recovery or cause complications.
(f) Estimate time-loss due to the injury or illness.
(4) Initial office and emergency room visit services may be performed by a network or nonnetwork provider. Services that are bundled with those performed during the initial visit (as defined in WAC 296-20-01002
), with no additional payment being due, are part of the initial visit.
(5) When the worker needs treatment beyond the initial office or emergency room visit, the network provider continues with necessary treatment in accordance with medical aid rules. If the provider is not enrolled in the provider network and the injured worker requires additional treatment, the provider will either:
(a) Apply for the provider network (if eligible) at the time he/she files the worker's report of accident; or
(b) Refer the injured worker to a network provider of the worker's choice.
(6) If the provider is not
the original attending provider, he/she should question the injured worker to determine whether a report of accident has been filed for the injury or condition. If no report of accident has been filed, it should be completed immediately and forwarded to the department or self-insurer, as the case may be, with information as to the name and address of original provider if known, so that he/she may be contacted for information if necessary. A worker must complete a request for transfer as outlined in WAC 296-20-065
if a report of accident has previously been filed and the provider is not enrolled in the provider network or the worker and provider agree that a change in attending provider is desirable.
[Statutory Authority: RCW 51.36.010
, 51.04.020, and 51.04.030. WSR 12-06-066, § 296-20-025, filed 3/6/12, effective 4/6/12. Statutory Authority: RCW 51.04.020
, 51.04.030, and Title 51 RCW. WSR 08-24-047, § 296-20-025, filed 11/25/08, effective 12/26/08. Statutory Authority: RCW 51.04.020
(4) and 51.04.030. WSR 86-06-032 (Order 86-19), § 296-20-025, filed 2/28/86, effective 4/1/86. Statutory Authority: RCW 51.04.020
(4), 51.04.030, and 51.16.120(3). WSR 81-01-100 (Order 80-29), § 296-20-025, filed 12/23/80, effective 3/1/81; Order 71-6, § 296-20-025, filed 6/1/71; Order 70-12, § 296-20-025, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-025, filed 11/27/68, effective 1/1/69.]