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PDFWAC 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) Provide a written explanation to the worker and provider(s) regarding any denied bill. Bills returned to the provider because a proper bill was not submitted under WAC 296-20-125 do not require a written explanation.
(4) Establish procedures to ensure prompt responses to inquiries regarding authorization decisions and bill adjustments.
(5) 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. WSR 19-01-095, § 296-15-330, filed 12/18/18, effective 7/1/19. Statutory Authority: RCW 51.36.010, 51.04.020 and 51.04.030. WSR 13-09-023, § 296-15-330, filed 4/9/13, effective 5/10/13. Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. WSR 06-06-066, § 296-15-330, filed 2/28/06, effective 4/1/06.]
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