Wash. Admin. Code § 296-20-125

Current through Register Vol. 24-21, November 1, 2024

Section 296-20-125 - Billing procedures

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.

Wash. Admin. Code § 296-20-125

Amended by WSR 15-17-104, Filed 8/18/2015, effective 10/1/2015

Statutory Authority: RCW 51.04.020, 51.36.080, 7.68.030, 7.68.080. 07-08-088, § 296-20-125, filed 4/3/07, effective 5/23/07. Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, § 296-20-125, filed 8/1/93, effective 9/1/93. Statutory Authority: RCW 51.04.020(4) and 51.04.030. 87-16-004 (Order 87-18), § 296-20-125, filed 7/23/87; 86-20-074 (Order 86-36), § 296-20-125, filed 10/1/86, effective 11/1/86; 86-06-032 (Order 86-19), § 296-20-125, filed 2/28/86, effective 4/1/86; 83-16-066 (Order 83-23), § 296-20-125, filed 8/2/83. Statutory Authority: RCW 51.04.020(4), 51.04.030, and 51.16.120(3). 81-01-100 (Order 80-29), § 296-20-125, filed 12/23/80, effective 3/1/81; Order 77-27, § 296-20-125, filed 11/30/77, effective 1/1/78; Emergency Order 77-26, § 296-20-125, filed 12/1/77; Emergency Order 77-16, § 296-20-125, filed 9/6/77; Order 75-39, § 296-20-125, filed 11/28/75, effective 1/1/76; Order 74-39, § 296-20-125, filed 11/22/74, effective 1/1/75; Order 74-7, § 296-20-125, filed 1/30/74; Order 71-6, § 296-20-125, filed 6/1/71; Order 70-12, § 296-20-125, filed 12/1/70, effective 1/1/71; Order 68-7, § 296-20-125, filed 11/27/68, effective 1/1/69.