Insurer Activity Prescription Form
Insurer Activity Prescription Form
About the Activity Prescription Form
L&I considers the effective use of the Activity Prescription Form (APF) as a best practice in occupational medicine. The form communicates an injured worker's physical restrictions and ability to work as well as the provider's treatment plans. In addition, workers' time-loss benefits depend on the APF and your chart notes.
Voc counselors can request an APF and other information
In addition to claim managers sometimes asking the attending provider for a new form, private vocational rehabilitation counselors are authorized to ask you to complete a new APF:
- If they need clarification or updated information on physical capacities, or
- If the worker's condition has changed.
If you recently submitted an APF and nothing has changed, ask the vocational provider to check the Claim & Account Center or to contact the insurer.
If you complete a new APF for a vocational provider, be sure to submit the form to L&I to ensure that you get paid for completing it.
Vocational providers may also request your review and response to:
- Job modifications or pre-job accommodations.
- Proposed work-hardening program.
- Plan for graduated, transitional, return-to-work.
What employers can ask
State Fund employers can contact the attending provider to clarify physical capacities related to returning to work. However, employers can't ask a provider to complete an APF. (L&I does not pay for APFs completed at the request of employers or attorneys.)
State Fund employers can also ask providers for:
- Concurrence with a performance-based physical capacities evaluation (PBPCE).
- Authorization for a worker to participate in a PBPCE.
You can remind employers to review the completed APFs that are a part of the worker's claim file in the Claim & Account Center.
Questions?
Call the Provider Hotline 1-800-848-0811 with your questions about the APF.
Ordering the Insurer Activity Prescription Form
The insurer will supply healthcare providers with an APF to complete with their request. Self-insurers or their third party administrators may send customized APFs.
Healthcare and vocational providers: Keep a supply of APFs in your office for submitting with a report of accident or Physician Intial Report (PRI) when there are physical restrictions. There are several ways to obtain APFs:
- Print one now
- Order online
You may add the APF to your electronic medical records system. All fields on the completed copy submitted to the department must appear in the same location as they appear on the department form. Contact Carole Horrell, Caroline.Horrell@lni.wa.gov for more information.
Healthcare and vocational providers: Fill out the order form below and L&I will mail the APFs to you.
Order by fax
Healthcare and vocational providers: Fax your order to the L&I Warehouse at 360‑902‑4525. Include in your faxed request the following information:
- "Insurer Activity Prescription Form - F242-385-000".
- Your name.
- Your company name.
- Mailing address.
- Telephone number.
- Quantity (copies are singles sheets, not pads).
Call the Provider Hotline 1-800-848-0811 for questions about the APF.
Completing the Insurer Activity Prescription Form
How do I complete the APF?
Health care providers must complete all portions of the form that apply to this worker's status. Writing "See chart notes" on the form is NOT acceptable. Chart notes are essential and must still be submitted for every visit billed.
What is required on the form to ensure payment?
| Section | Required information |
| General Info | All fields must be completed. Patient ID (peel and stick) labels may be used, as long as all the requested information is provided. ICD-9 codes or written diagnoses may be used. |
| Released for work? | One section must be completed to indicate work status. Dates or a time span must be included. |
| Key Objective Finding(s) | If the worker is not returned to full duty, objective medical findings (OMF) must be documented. OMFs are verifiable on exam. Examples are:
|
| Estimate of what the worker can do | Capacities are applicable 24 hours a day, not just at work. Restrictions must be provided even when the patient is off work. Including current restrictions may enable employers to identify appropriate light/modified duty jobs. The Key Objective Findings must support your restrictions.
The Health Care Provider can document the estimate of what the worker can do by either:
|
| Plans | Your plan must be documented. Please include your assessment of progress, any rehabilitation, and if treatment is continuing or concluded. This information is critical for claim management decisions. |
| Sign | Your signature and date must be provided. Note: About impairment ratings Qualified attending health-care providers include doctors currently licensed in medicine and surgery (including osteopathic and podiatric) or dentistry, and chiropractors who are department-approved examiners. |
Clinical scenarios and form samples
Note: If a worker has more than 1 injured body part in the "Note to Claim Manager", indicate how you have marked the "Doctor's Estimate of Physical Capacities." For example: 1=left knee, 2=left shoulder.
Sample 1: Worker requires temporary, modified duty while recovering from injury. Complete all sections. See sample 1 (67 KB PDF).
Sample 2: Worker is off work due to an industrial injury or occupational disease. Complete all sections. See sample 2 (68 KB PDF).
For questions about the APF, call Provider Hotline 800-848-0811.
Authorization requirements
Health care providers are only authorized to submit APFs along with a report of accident (ROA) or Providers Initial Report (PIR). The ROA/PIR must show the worker has physical work-related restrictions that must be accommodated for light duty work.
If the insurer requires additional APFs, they will send a request letter with a blank APF.
| Which situations do or do not require an APF with the ROA/PIR and chart notes? | |
|---|---|
| If the worker: | Submit APF? |
| Is released to work without restrictions | No |
Has a simple injury without restrictions. For example:
| No |
Has a simple injury with restrictions that do not require light/modified duty. For example:
| No |
| Has work-related physical restrictions that must be accommodated for light-duty work. | Yes |
| Is an office visit necessary when the insurer asks you to complete an APF? | ||
| If you: | Office visit? | Then: |
| Examined the worker within the last 30 days | No | Use information from your last visit as the basis for your opinion. |
| Are uncertain about the worker's current need for treatment or work restrictions or It has been more than 30 days since you examined this worker. | Yes | Schedule an appointment with the worker as soon as possible. |
| Are no longer treating this worker. | No | Indicate the last known status and return the form as soon as possible. |
| Concluded treatment. | No | Complete the portions of the form that apply to the worker's medical status when you conclude treatment, including the "Plans" section. |
For questions about the APF, call Provider Hotline 1-800-848-0811.
How do health care providers bill for using the Insurer Activity Prescription Form?
Payment Policies
Activity Prescription Forms (APF) are payable only when all relevant sections of the form are completed, legible and:
- When submitted with a Report of Accident (ROA) or Providers Initial Report (PIR) where the worker has physical restrictions.
or - Upon the request from the insurer or vocational counselor.
Note: APFs are not payable when submitting an Application to Reopen Claim (F242-079-000). Insurers may request APFs on reopened claims.
Who can bill for filling out the APF
The APF will be payable to:
- Doctors, as defined in WAC 296-20-01002 including:
- Attending doctors.
- Transfer doctors.
- Concurrent care doctors.
- Consultants.eee
- Advanced Registered Nurse Practitioners (ARNPs).
- Physician Assistants (PAs).
Who can not bill for filling out the APF
Occupational therapists, physical therapists, office staff and others cannot be paid for working on or completing the APF form.
Billing codes and fees
| Code | Fee | Description | Limit |
|---|---|---|---|
| 1074M | $30.51 | Written response to VRC or employer requests for information on return to work | As requested, but not to exceed once per provider per worker per day |
| 1073M | $49.57 | Insurer Activity Prescription Form (F242-385-000) | As requested, but not to exceed 1 APF, per provider, per worker, per day. |
Billing codes for phone calls to insurer, employer, and vocational rehab counselors
To bill health care providers' telephone call/consultation regarding care of injured workers, use:
- CPT® codes 99441 to 99443 and 98966 to 98968.
- CPT® code book for entire descriptions.
- For complete payment policies and documentation requirements, see the Payment policies (1,189 KB PDF / 7 min ).
Electronic billing
For information on billing L&I electronically, see our Electronic Billing site. Payment is much faster than using paper billing.
Paper billing
Submit bills by completing APFs on CMS 1500 forms (F245-127-000).
For questions about the APF, call Provider Hotline 1-800-848-0811.
What are the documentation and recordkeeping requirements?
What kind of documentation do I need to do?
- SOAPER notes and reports are required as usual, even when the insurer requests an APF.
- Chart notes in SOAPER format include:
- S - Worker's subjective complaints.
- O - Doctor's objective findings.
- A - Doctor's assessment.
- P - Plan.
- E - Employment.
- R - Restrictions.
- If there are multiple claims for a worker, put all claim numbers on the:
- APFs
- Bills,
- Chart notes and
- Reports.
- Send the completed APF to the insurer.
Give a copy of the APF to the worker, so they can show it to their employer.
For more information on chart note and report requirements, see pages 24-25 of the Attending Doctors' Handbook (F252-004-000).
What are the recordkeeping requirements?
Keep APFs, chart notes, reports and other information in your files for a minimum of 5 years for audit purposes.
