Find out What Requires Prior Authorization
There's more than one way to get it
Utilization review is the process of having a request for certain services reviewed by a clinical person for medical necessity and quality criteria matching before authorization can be granted. Use our Authorization and Referrals page to determine what needs authorization and who to contact.
When requesting surgery, physical therapy, spinal injections and advanced diagnostic imaging, use our evidence based treatment guidelines and coverage decisions and submit your authorization requests to the Comagine Health web portal from One Health Port. L&I values high quality health care provider partners, and for some services, providers who have 100% approvals can qualify for express authorization.
Know What can be Billed and Paid
The fee schedule and payment policies
When you render treatment to a worker covered by L&I or a self-insured employer, you are agreeing to abide by L&I’s Medical Aid Rules (WAC 296-20-020), and accept established reimbursement amounts for each service as full payment. L&I’s Fee Schedules and Payment Policies, tells you what services and products are covered, along with policies, payment methods and maximum fees. It applies to health care and vocational providers who treat injured workers and crime victims. Chapter 2 is particularly helpful. L&I’s coverage decisions listing provides more in depth information about specific conditions and treatments.
Learn What Reports and Paperwork are Payable
Get paid for paperwork
You can be paid for completing certain reports that the department or self-insured employer requests of you. Just be sure to include the required information and send it to the correct place so your payment will not be delayed, reduced, denied, or recouped. Here are some resources:
- Documentation & Reporting provides a partial list of reports and forms, along with L&I’s expected turn-around times and due dates.
- Quick Reference Fee Schedule provides a list of some of the common forms and services that are payable in addition to your evaluation and management services.
- Submitting Bills and Reports provides instructions for the best way to submit these documents to ensure they go to the right place and prevent delays in payment.
Use the Correct Billing Procedures
Prevent payment delays
Bills may be submitted electronically or with paper. Check out these resources for instructions:
- General Provider Billing Manual provides complete instructions for how to submit bills, what forms to use, how to deal with special situations, and who to contact for questions.
- Billing L&I provides information similar to the billing manual and links to free billing workshops.
- Provider Express Billing is a free and secure way to submit or adjust bills electronically 24/7 and receive remittances through My L&I.
Use Different Billing Procedures with Self-insured Employers
Or their administrators
When you treat a worker insured by their employer rather than by the State Fund, submit bills directly to the employer or their representative.
To determine if an employer is self-insured you can check L&I’s public website for SIEs and third-party administrators or you can contact L&I’s Self-Insurance section.
Although they use different forms, SIEs must follow the same laws and rules as State Fund employers, and they or their representatives are responsible for the payment of bills and authorization of medical treatment.