Insurer Activity Prescription Form
 

About the Insurer Activity Prescription Form (APF)

Effective November 1, 2007.

Why is L&I releasing this new form?

To reduce health care providers' paperwork:

  • By reducing the number of requests for information about L&I clients.
  • By providing integrated medical information on injured workers' conditions, restrictions and prognoses.
  • There will be a transition period:
During the transition period for dates of service of November 1, 2007 through January 31, 2008: L&I will pay health care providers for physical capacities information requested by vocational rehabilitation counselors (VRCs) and employers.
After the transition period, beginning February 1, 2008: Private VRCs and State Fund employers can obtain physical capacity information by:
  • Using doctor-completed APFs that are a part of the worker's claim file and can be viewed in L&I's Claim and Account Center,
  • Requesting an APF through the claim manager when updated physical capacity information is needed.
  • Asking doctors for information regarding return to work. Both VRCs and State Fund employers may seek:
    • concurrence with a performance based physical capacities evaluation (PBPCE).
    • authorization for worker to participate in a PBPCE.

    Additionally, VRCs may ask a provider to review and respond to:

    • job modification or pre-job accommodation.
    • proposed work hardening program.
    • plan for graduated, transitional, return-to-work.

Attention Providers:

You may respond to an employer’s request for a worker's physical restrictions:

  • to help with return to work efforts,
  • if you have not provided that information on an Activity Prescription Form (APF) submitted with the report of accident or at the insurer’s request.
  • if the restrictions you have previously provided on an APF have changed.

 Bill code 1074M for this service.

If you’ve submitted a completed APF, inform the employer and VRC that they can obtain the workers’ physical restrictions from the insurer.


By replacing multiple forms with one using the following schedule
  • Time Loss Notification (F242-036-555, F242-036-909, F242-036-999) - Recycle after Nov 15, 2007.
    Note: Worker verification forms (WVFs) will be sent to the workers who may be eligible to receive time-loss compensation. Only the worker signs this form. If necessary, your signature on APFs will also certify time-loss compensation.
  • Order WVFs and keep a supply in your office (F242‑052‑000).
  • Supplemental Medical Report (F242-108-000, F242-051-000) - Recycle after Nov 15, 2007.
  • Physician Final Report (Not a form) - Recycle after Nov 15, 2007.
  • Doctor's Estimate of Physical Capacities (F242-002-000) - Recycle after Jan 31, 2008.
  • Physical Capacity Evaluation (Not a form) - Recycle after Jan 31, 2008.

The APF communicates:

  • Work status,
  • Work-related physical restrictions,
  • Verification of time-loss, if appropriate, and
  • Treatment plans.

Note: Health care providers in the Centers of Occupational Health & Education and the Orthopedic/Neurologic Pilot Projects will continue to follow the APF use and billing instructions provided by those projects.

Health care providers will continue to be paid for activities supporting return-to-work including:

  • Consultation with employers and VRCs, and
  • Review of job descriptions and job analyses.

Call the Provider Hotline 1-800-848-0811 with your questions about the APF.


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