Help us provide the necessary care for the injured worker and pay you promptly.
Make sure the required documentation (reports, chart notes, etc.) is faxed or mailed correctly. We may deny or reduce payment if the required documentation is not provided or the level or type of service does not match the procedure code billed.
To reduce your claim (bill) delays, follow the suggestions below:
- Don’t fax bills. We do not accept any bills that are faxed, they will not be processed.
- Put the L&I claim number in the top right corner of every page of each document.
- Use only plain, white paper and do not highlight, to assure clear imaging.
- Do not use address stamps or labels that are too large for a form.
- Make sure documentation is legible.
- Send reports and chart notes separately from bills. See addresses on the "Mailing Addresses" tab above.
- Fax your chart documents to us, because faxed information goes directly to the claim file.
For desk references
General Provider Billing Manual (F245-432-000)
For additional questions contact the Provider Hotline at PHL@Lni.wa.gov or 1-800-848-0811.
Chart notes and narrative reports require the following format
In workers' compensation there is a unique need for work status information. To meet this need it is suggested adding "ER" to the "SOAP" format.
Plan and progress.
Employment issues: Include a record of the patient's physical and medical ability to work, and information regarding any rehabilitation that the worker may need to undergo.
Restrictions to recovery: Any temporary or permanent physical limitations, and any unrelated condition(s) that may impede recovery.
Reports and Documents to submit
What documents are required by health care providers and when they are due.
|Document||Due to L&I or Self-Insurer|
|Report of Industrial Injury or Occupational Disease form (F242‑130‑000). Order forms by completing an online request.||Immediately — within 5 days of first visit.|
|Self-Insurance: Provider's Initial Report (PIR)(F207-028-000).||Immediately — within 5 days of first visit.|
|Sixty Day narrative — Support and document the need for continued care when conservative (nonsurgical) treatment is to continue beyond 60 days.||Every 60 days.|
|Special Reports/Follow-up Reports narrative — To update L&I on the treatment and status of your patients.||As soon as possible following request by L&I or Self-Insurer. |
|Consultation Examination Reports narrative — Obtain an objective evaluation of the need for ongoing conservative medical management of the worker. The attending doctor may choose the consultant.||At 120 days.|
|Attending Doctor Review of IME Report letter — Obtain the attending doctor's opinion about the accuracy of the diagnoses and information provided based on the Independent Medical Exam (IME).||As soon as possible after receipt.|
|Activity Prescription form (F242‑385-000) — Summarize ability to work, restrictions and treatment plan. Form can be completed or submitted electronically.
To order paper forms, email the L&I warehouse at firstname.lastname@example.org or send a request to:
Washington State Department of Labor & Industries
Labor & Industries Warehouse
PO Box 44843
Olympia WA 98504-4843
|As soon as possible after receipt.|
|Loss of Earning Power form (F242‑208‑000) — Certify the loss of earning power is due to the industrial injury/occupational disease.
To get form fax the L&I warehouse at 360-902-4525 or email whse@Lni.wa.gov.
|As soon as possible after receipt. |
|Application to Reopen Claim Due to Worsening of Condition form (F242‑079‑000) — To notify L&I that the accepted condition has worsened and the claim needs to be reopened for additional treatment. Use this form if the claim has been closed for more than 60 days or for Crime Victims more than 90 days.||Immediately|
Mailing addresses for billing documents
|If you are submitting...||Send your bills...|
|Provider Account information including updates||Department of Labor & Industries
PO Box 44261
Olympia, WA 98504-4261
|All bills and adjustments||Department of Labor & Industries
PO Box 44269
Olympia, WA 98504-4269
|Refunds (attach copy of remittance advice)||Department of Labor & Industries
PO Box 44835
Olympia, WA 98504-4835
Reports and Chart Notes
|Document type||Where to send claim information|
|Report of Industrial Injury or Occupational Disease
OR mail it to:
Department of Labor & Industries
PO Box 44299
Olympia, WA 98504-4299
|Correspondence; reports and chart notes
(in SOAPER format) and claim related documents other than bills.
Note: Don't fax bills!
OR mail it to:
Department of Labor & Industries
PO Box 44291
Olympia, WA 98504-4291
Most billing forms are available for download from the L&I website.
(For Crime Victims forms)
Select the form name below to go a fillable form online.
- CMS 1500 (F245-127-000)
- Provider’s Request for Adjustment (F245-183-000)
- Statement for Compound Prescription (F245-010-000)
- Statement for Home Nursing Services (F248-160-000)
- Statement for Miscellaneous Services (F245-072-000)
- Statement for Pharmacy Services (F245-100-000)
- Statement for Retraining and Job Modification Services (F245-030-000)
- UB04 HCFA 1450 (F245-367-000)