Mental Health Treatment in Workers' Compensation

This website is a summary of information related to mental health treatment and workers’ compensation in Washington State. Providers can find details in the Mental Health Provider Resource.

Mental Health Provider Resource

The Mental Health Provider Resource includes information related to what providers must document in an initial evaluation (e.g., diagnosis, causation and treatment plan), examples of mental health conditions that may be covered, services from different mental health providers, authorization and reporting requirements, an emphasis on return to work, and report examples.

When treatment is covered

• The insurer has authorized the initial evaluation and subsequent treatment (up to 90 days at a time).
• The mental health condition is caused or aggravated by a work-related injury or occupational exposure.
• There is documented measurable improvement in targeted specific symptoms and functional status.
• The insurer has authorized temporary treatment of a pre-existing or unrelated mental health condition that is delaying recovery of the work-related injury or illness.

Treatment that is NOT covered

• Palliative care (when treatment is not curative and rehabilitative).
• Treatment has reached maximum medical improvement.
• Temporary treatment does not improve physical function of the industrial injury or occupational disease.

Use of DSM-5 criteria is required

L&I or the self-insurer uses your information to determine the relationship between industrial injuries and mental health conditions.

During evaluation and ongoing reports, you must clearly indicate your opinion about the possible relationship between a mental health condition and an industrial injury — and the basis for your opinion using the criteria of the American Psychiatric Association’s Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Authorization Requirements

Prior authorization is required for the initial evaluation. Prior authorization is not needed if the evaluation is performed to initiate a claim filed solely for mental health conditions. Prior authorization for treatment may be granted in increments of up to 90 days.

How to request prior authorization for mental health services

Reporting requirements - timeline

Reporting requirements summary

Initial evaluation must include at least the following:

• DSM-5 diagnosis and explanation of how all criteria are met,
• Statement on causation, and
• Treatment plan.

Issues such as causation can be complicated, particularly as it relates to workers’ compensation claims. The Mental Health Provider Resource clarifies the specific information a provider must consider on this topic.

Each chart note (or report upon request) must include at least the following:

• Diagnosis, explicitly using DSM-5 criteria and the appropriate specifier (e.g., severe vs. mild, partial remission vs. in remission),
• Relationship of the diagnosis, if any, to the industrial injury or occupational disease,
  Summary of subjective complaints,
• Objective findings (e.g., appearance and behavior, mood and affect, cognitive function),
  Assessment of functional status at baseline and every 30 days,
• Goal-directed, time limited treatment plan focusing on functional restoration and return to work,
• Medications prescribed,
• Response to treatment, and
• Barriers to recovery.

Special emphasis on return to work

• Document positive outcomes when treatment facilitates a return to work.
• If the worker is unable to return to work due to an accepted mental health condition, a provider’s estimate of functional status and barriers to work should be included with the report.
• Describe if and how the mental health condition interferes with specific job tasks.
• Summarize which targeted specific symptoms must improve to allow a successful return to work status, including a plan to achieve the goal.
• Determine whether the worker is able to engage in modified work, which may include relevant accommodations.
• Comment on whether the worker is able to return to their regular work status, considering mood, behavioral, and/or cognitive factors.

See the Mental Health Provider Resource for report examples.

Functional Assessment at Baseline and Every 30 days

Providers must track and document the worker's functional status using validated instruments such as the World Health Organization Disability Assessment Schedule (WHODAS) version 2.0 or other substantially equivalent validated instruments recommended by the department (WAC 296-21-270). Due to scoring differentials, the same instrument must be used each time for that worker. The purpose is to determine the degree of change in the process of rehabilitation and function.

The approved assessment instruments are:

• World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), 36 or 12 item version
  • Health and disability
• Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 or CAT method, and Short-Form Survey 36- or 12-item (SF-36 or SF-12)
  • Health-related quality of life.

Symptom severity

Consideration should also be given to the use of standardized instruments to measure symptom severity for mental health conditions such as depression, anxiety, or posttraumatic stress disorder. Such measurements provide support for a diagnosis and benchmarks against which progress in treatment can be measured.

See the Mental Health Provider Resource for details.

Billing and Payment

Billing codes and payment policies

• Fee Schedules and Payment Policies (MARFS) 

Pre-authorization is key

1. For claims covered by L&I, contact the claim manager or use the downloadable preauthorization form for authorization to provide services.

2. When you receive your authorization, check the authorized dates of service. If they are different from what you expected, contact the claim manager immediately. Do not provide services beyond the authorized dates.

3. Request an extension two weeks before the end of the currently authorized period to reduce the possibility of a disruption in care.

4. Additional treatment is more likely to be authorized if your notes/reports clearly show the injured worker is improving as a result of the therapy.

For claims covered by self-insured employers, contact the self-insured employer or their third party administrator for prior authorization.

Other billing information

1. It’s important to know who and where to bill:
   • Washington State workers’ compensation State Fund claims begin with 2 alpha characters followed by 5 numeric characters (for example, BB12345, ZB12345): Billing L&I
   • Self-Insured Employer claims begin with S, T, or W (for example, SZ12345): Billing Self-Insured Employers
2. Bill L&I electronically using our free online Provider Express Billing system to bill for State Fund claims. Electronic bills process faster.
3. When submitting bills, remember to:
   • Use dates of service only within the authorized date span.
   • Use ICD-10 diagnosis codes. If you are making a new diagnosis, or adding one, then discuss the new diagnosis with the claim manager.
   • Bill for the work you do, including phone calls (see Chapter 10 above), electronic communications (Claim & Account Center), return to work offers, and 60-day reports. See our Mental and Behavioral Health Fee Schedule.
4. Include the diagnosis you made during your assessment. A mental health condition may not have been be allowed on your patient’s claim yet. The claim manager will review your report to determine if it should be accepted on that claim.
5. Mental Health providers may request temporary access to the Claim & Account Center to access the patient’s claim file.

• • Consulting or concurrent care providers may call the claim manager to request 90-day access.
  • Need assistance signing up? Call Web Customer Support at 360-902-5999.

Resources

L&I's Mental Health Provider Resource

Other Resources