Do you need to be in the Medical Provider Network?

Note: If you are not one of the specialty types listed below, this is not your application, see apply for a provider account (F248-011-000).

If you practice in Washington State and are one of the following provider types, you must be in our network to care for injured workers beyond the initial office or emergency-room visit. This includes treatment for workers of business covered by L&I as well as those employed by self-insured employers:

• • Physician (MD & DO)
  • Advanced Registered Nurse Practitioner
  • Chiropractor
  • Dentist
  • Naturopathic Physician
  • Optometrist
  • Physician Assistant
  • Podiatric Physician

How to apply to be a Network Provider

You have two options:

Option 1: Apply on paper

1. Complete, print, and sign the following:

Medical Provider Network Application Packet (F245-447-000) and Washington Practitioners Application (F245-411-000) (WPA)

• • Please follow the instructions in section one of the WPA, and
  • Submit current copies of the documents noted in Section 1.
  • Before submitting your complete application,
    • Verify the Tax ID on the Office of Financial Management (OFM) Vendor/Payee Registration form (Step 3, below) and the Tax ID on page 2 of the WPA match.
    • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form. (Step 3, below) 
    • This will ensure your vendor/payee number is associated to your L&I provider account.  

2. Send your application materials to:

Fax:  360-902-4563
Mail:
Provider Accounts and Credentialing
P O Box 44261
Olympia, WA 98504-4261

Note: The OFM forms (Step 3, below) must be completed concurrently with the submission of the WPA to avoid potential delays in payment.  

3. The Office of Financial Management (OFM) will need to register your Tax ID to issue payments.  You will need to submit forms directly to OFM for: 

• New Tax ID
• Enrollment/change for EFT payments
• Updates to the Legal Name associated with your Tax ID
• OFM forms can be found by following the link: ofm.wa.gov/payee  

• • • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form.  
    • This will ensure your vendor/payee number is associated to your L&I provider account.  

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov. 

It is the provider's responsibility to submit the necessary forms to OFM, directly. L&I cannot accept or forward OFM forms on behalf of the provider. 

Option 2: Apply online with OneHealthPort (OHP)

1. First, please read, sign, and submit the following: 

• Provider Agreement (F245-397-000), and
• A copy of your Federal IRS Form W-9 (for Tax ID listed on WPA, page 2).

Please make sure your request includes: 

• A request to pull the provider application from OHP
• The provider name
• The provider's Individual NPI number

2. You may fax, email or mail the completed L&I forms to the following:

Fax:  360-902-4563
Email: ProvNet@Lni.wa.gov
Mail:
Provider Accounts and Credentialing
P O Box 44261
Olympia, WA 98504-4261

Note: The OFM forms (Step 3, below) must be completed concurrently with the submission of the WPA to avoid potential delays in payment.

3. The Office of Financial Management (OFM) will need to register your Tax ID to issue payments. You will need to submit forms directly to OFM for: 

• New Tax ID
• Enrollment/change for EFT payments
• Updates to the Legal Name associated with your Tax ID
• OFM forms can be found by following the link: ofm.wa.gov/payee

• • • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form.  
    • This will ensure your vendor/payee number is associated to your L&I provider account.  

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@omf.wa.gov

It is the provider's responsibility to submit the necessary forms to OFM, directly. L&I cannot accept or forward OFM forms on behalf of the provider.   

4. Follow OneHealthPort's Getting Started/Sign In instructions for setting up your account correctly in ProviderSource.

Note: If you already have an established account in ProviderSource, proceed to step five.

5. Apply online through the OneHealthPort website.

6. Verify the Tax ID on the OFM  vendor/payee form (Step 2) matches the Tax ID on page 2 of the WPA.

• • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form. 
  • This will ensure your vendor/payee number is associated to your L&I provider account. 

7. Make sure you check the L&I box in the Attestation tab.

8. You must re-attest so we may receive your application.

Is your application complete?

Incomplete applications or missing information delays account set up and payment of services to you.

To ensure timely processing, use the Medical Provider Network Credentialing Checklist (F245-445-000) to identify missing information.

What to expect from L&I

To process complete applications, allow 120 days. If additional information is needed to process your application, we will contact you.

You will receive a letter in the mail once your application is processed.

What is my application or network status?

Having a provider account number or reactivating a closed account does not mean you are in our network. If you do not see that you are a network provider and want to treat an injured worker for ongoing care, you must apply.

To check your application or network status, search by:

L&I provider number or National Practitioner Identification (NPI) number

What happens if I don't join?

If you treat an injured worker for ongoing care, beyond the initial visit to file the Report of Accident form, you must be an approved network provider to be paid for services. Please refer the injured worker to a network provider.

Find a network provider for patients that need ongoing care.

Provider Account Number (non-network)

If you are not one of the provider types required to join our network, or if you practice out-of-state, you should apply for a provider account number with L&I.

Here's how to apply:

1. Complete a Provider Account Application (F248-011-000).

If you are one of the following provider types, you have additional requirements. To fulfill those requirements, visit:

• Chiropractic consultant
• Independent medical examiner
• Interpreter
• Masters Level Therapists (MLTs)* - L&I's Pilot Program
  • MLTs may enroll and provide care in the Crime Victims Compensation program without participating in the MLT pilot
  • *MLTs include Licensed Independent Clinical Social Workers (LICSWs), Licensed Marriage and Family Therapists (LMFTs), and Licensed Mental Health Counselors (LMHCs)
• PGAP® Activity Coach
• Vocational provider
• Work-hardening provider

2. Submit your completed L&I application (including additional requirements, if indicated above) to:

Fax: 360-902-4484
Mail:
Provider Accounts and Credentialing
P O Box 44261
Olympia, WA 98504-4261

Note: The OFM forms (Step 3, below) must be completed concurrently with the submission of the Provider Account Application to avoid potential delays in payment.

3. The Office of Financial Management (OFM) will need to register your Tax ID to issue payments. You will need to submit forms directly to OFM for: 

• New Tax ID
• Enrollment/change for EFT payments
• Updates to the Legal Name associated with your Tax ID
• OFM forms can be found by following the link:  ofm.wa.gov/payee
  • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form.  
  • This will ensure your vendor/payee number is associated to your L&I provider account.  

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov.

It is the provider's responsibility to submit the necessary forms to OFM, directly. L&I cannot accept or forward OFM forms on behalf of the provider. 

Next Steps

Allow 60 - 90 days for review of your application. We will notify you of our decision. If you are accepted, you will receive a letter notifying you of your provider account number. After 90 days, if you haven't heard from us, please email us at PACMail@Lni.wa.gov.

Out of State Providers - Apply for a Provider Account

If you are a provider who practices Out of the State of Washington, you will need to:

1. Submit the Provider Account Number Application (F248-011-000) for us to pay you for services rendered.

Submit your completed L&I application to:

Fax: 360-902-4484
Mail:
Provider Accounts and Credentialing
P O Box 44261
Olympia, WA 98504-4261

Note: The OFM forms (Step 2, below) must be completed concurrently with the submission of the Provider Account Application to avoid potential delays in payment. 

2. The Office of the Financial Management (OFM) will need to register your Tax ID to issue payments. 

You will need to submit forms directly to OFM for: 

• • New Tax ID
  • Enrollment/change for EFT payments
  • Updates to the Legal Name associated with your Tax ID
  • OFM forms can be found by following the link: ofm.wa.gov/payee
    • On the OFM Vendor/Payee Registration form, circle MIPS use only on the top right hand corner of the form.  
    • This will ensure your vendor/payee number is associated to your L&I provider account.  

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov.

It is the provider's responsibility to submit the necessary forms to OFM, directly. L&I cannot accept or forward OFM forms on behalf of the provider. 

Next Steps

Allow 60 - 90 days for review of your application. We will notify you of our decision. If you are accepted, you will receive a letter notifying you of your provider account number. After 90 days, if you haven't heard from us, please email us at PACMail@Lni.wa.gov.

Out-of-Country Providers — Apply for a Provider Account

If you are a provider who is providing services outside of the United States, you will need to submit the following application for us to pay you for your services rendered:

• Out-of-Country Provider Account Application (F248-361-000), English
• Solicitud de cuenta como proveedor fuera del país (F248-361-999), Spanish

If payment for services are being issued to a hospital, facility or clinic, the W-8BEN-E form is required instead of the W-8BEN. Please click on the following link, below, to download and complete W-8BEN-E:

• IRS W-8BEN-E Form (F248-371-000), English
• Formulario W-8BEN-E del IRS (F248-371-999), Spanish

Please note: Hospitals, facilities or clinics who receive payment for services, do not need to complete the W-8BEN that is included with the Out-of-Country Provider Account Application. The W-8BEN is for individual providers only.

Submit your completed application by fax or US mail to:

Fax: 360-902-4484

Mail:
Washington State Department of Labor & Industries
Provider Accounts and Credentialing
PO Box 44261
Olympia, WA 98504-4261
United States of America

Next steps

Allow 60 - 90 days for review of your application. We will notify you of our decision. If you are accepted, you will receive a letter notifying you of your provider account number. After 90 days, if you have not heard from us, please email us at PACMail@Lni.wa.gov.

Changes to your account

Changes may cause bill payment delays and access issues with L&I's online applications, such as Provider Express Billing and your My L&I account. 

To prevent delays, make sure everyone in your organization knows about the change, including billing staff and staff at individual clinic locations. 

1. For new locations or a new business, submit the Out-of-Country Provider Account Application (F248-361-000), and follow the steps outlined above.
2. For address, name, account closures or other changes on existing accounts, providers must:
   1. Complete, print and sign:
      • Out-of-Country Change Form (F245-469-000, English, or
      • Solicitud de cuenta como (Change form), (F245-469-999), Spanish
   2. Changing your name?
      1. Individual providers who are changing their name, please include one of the following: 
         • Updated Medical License
         • Marriage Certificate
         • Divorce Decree, or
         • Court ordered documents with your new name.
      2. For hospitals, facilities or clinic name changes, please include a copy of your facility license, certification and/or accreditation that includes the new name.

Submit your completed forms by fax or U.S. mail to:

Fax: 360-902-4484

Mail:
Washington State Department of Labor & Industries
Provider Accounts and Credentialing
PO Box 44261
Olympia, WA 98504-4261
United States of America

How L&I sets up accounts, what you need to know.

If you have multiple locations, under the same Tax ID with one or more organizational national provider identification (NPI) numbers, it's important to know how we set up accounts. It can lead to delayed or denied payments.

How you set up your accounts is an administrative decision. When a provider applies, L&I looks at page 2, section 3 of the Washington Practitioners Application and the current IRS Form W-9 attached for each location submitted.

Accounts are generally set up based on two scenarios. Here's what you should know:

Scenario 1

• A group has multiple locations under the same Tax ID and one organization NPI. In this scenario, L&I only sets up one group payee account for the Tax ID and organization NPI listed, regardless of how many locations may be associated with the group. This prevents bills from suspending in our system, which leads to delays in payment of services.

Scenario 2

• A group has multiple locations under the same Tax ID with multiple organization NPI's for each location. In this scenario, L&I will set up a group payee account for each location with a separate organization NPI. When a provider applies, attaching page 2, section 3 of their Washington Practitioners Application for each location, L&I will set up an individual provider account for each location that has a separate organization NPI.

If a group with multiple locations under the same Tax ID and organization NPI would like their providers set up for each practice location, they must submit an Add Group Packet (F245-449-000) for each network provider and location.

Note:  The OFM forms (noted below) must be completed concurrently with the submission of the Add Group Packet to avoid potential delays in payment. 

The Office of Financial Management (OFM) will need to register your Tax ID to issue payments. 

You will need to submit forms directly to OFM for:

• • New Tax ID
  • Enrollment/change for EFT payments
  • Updates to the Legal Name associated with your Tax ID
  • OFM forms can be found by following the link: ofm.wa.gov/payee

For questions regarding OFM forms or the registration process, call 360-407-8180 or email: PayeeRegistration@ofm.wa.gov. 

It is the provider's responsibility to submit the necessary forms to OFM, directly. L&I cannot accept or forward OFM forms on behalf of the provider. 

If you do not have an organization NPI for each location and you request to add each group, please be aware, this will result in delayed processing if you bill using a provider individual NPI number and not their L&I provider account number for each practice location.

To prevent these delays you must put the individual provider account number in box 24J of the CMS 1500 billing form or each practice location or the group ID payee number in box 33B to indicate which practice location the services were rendered.