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Washington Workers' Compensation Legal Library


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296-15-420 After a self-insured claim is filed.

(1) What must a self-insurer do when beginning time loss (TL) benefits on a claim?
When
Send to the worker
Send to the department
The department will
On the date of the first TL payment.
A complete and accurate SIF-51 and SIF-5A2.
Within 5 working days of first TL payment.
Copies of the SIF-2, SIF-5, and SIF-5A.
Allow the claim UNLESS a request for interlocutory order (see subsection (2)) or denial (see subsection (3)) has been received.
If kept on salary3, within 5 working days of the date the first TL payment would have been due.
A complete and accurate SIF-5 and SIF-5A.
Copies of the SIF-2, SIF-5, and SIF-5A.
Allow the claim UNLESS a request for interlocutory order (see subsection (2) of this section) or denial (see subsection (3) of this section) has been received.
1
The SIF-5 is the Self-Insurer's Report on Occupational Injury or Disease. Use a form substantially similar to L&I form F 207-005-000.
2
The SIF-5A is the Time Loss Calculation Rate Notice. Use a form substantially similar to L&I form F 207-156-000.
3
If the worker is kept on salary, report the amount of time loss the worker would have been entitled to on the SIF-5.
(2) How must a self-insurer request an interlocutory1 order?
When requesting an interlocutory order from the department, a self-insurer must:
When
Send to the worker
Send to the department
The department will
And the self-insurer pays
Within 602 days of claim filing.
A complete and accurate SIF-5 and SIF-5A if TL was paid or if worker was kept on salary.
Copies of the SIF-2, SIF-5 (with the interlocutory order box checked), SIF-5A, AND all records excluding bills AND a reasonable explanation why an interlocutory order is needed.
If it agrees, issue an interlocutory order.
Provisional TL if the worker is eligible AND other benefits as entitled. Ongoing medical treatment and vocational services are NOT PAYABLE unless the claim is allowed.
If it disagrees, issue an allowance order if the facts show the claim should be allowed.
TL if the worker is eligible, and other entitled benefits.
1
An interlocutory order places a claim in provisional status while the self-insurer investigates the validity of the claim.
2
When not specified, time is in calendar days.
(3) How must a self-insurer request claim denial from the department?
When requesting claim denial from the department, a self-insurer must:
When
Send to the worker
Send to the department
The department will
And the self-insurer pays
Within 60 days of claim filing.
SIF-4.1
Copy to the attending or treating doctor.
SIF-4 AND all records excluding bills.
If it agrees, issue a denial order.
The denial order will restate the self-insurer's right to request reimbursement of provisional TL from the worker.
For all medical evaluations and diagnostic studies used to make the determination.
If it finds insufficient information to make a decision, issue an interlocutory order AND direct the employer to obtain the necessary information.
Provisional TL if the worker is eligible and other benefits as entitled.
Ongoing medical treatment and vocational services are NOT PAYABLE unless the claim is allowed.
If it disagrees,
issue an allowance order if the facts show the claim should be allowed.
TL if the worker is eligible AND other entitled benefits.
1
The SIF-4 is the Self-Insured Employer's Notice of Denial of Claim. Use a form substantially similar to L&I form F 207-163-000.
(4) What if a self-insurer does not request allowance, denial, or an interlocutory order for a claim within sixty days?
If a self-insurer does not request allowance, denial, or an interlocutory order within sixty days, the department will intervene and adjudicate the claim. The department may obtain additional medical information to make the determination. The claim remains in provisional status until the department makes the determination.
The exception to this requirement is the allowance of medical only claims. Self-insurers are not required to request allowance for medical only claims.
(5) Must a self-insurer submit an SIF-5 each time the department requests one?
Yes. A self-insurer must submit a complete and accurate SIF-5 within ten working days of receipt of a written request from the department.
(6) What must a self-insurer do when the department requests information on a claim by certified mail?
A self-insurer must submit all requested information concerning the claim within ten working days of receipt of the department's request by certified mail.
(7) How long does a self-insurer have to provide a copy of the claim file to the worker or worker's representative?
A self-insurer must provide a copy of the claim file within fifteen days of receiving a written request from the worker or worker's representative. Unless the worker or representative requests a particular portion of the file, the self-insurer must provide a copy of the entire file.
(8) When may a self-insurer charge a worker or his/her representative for a copy of the claim file?
A self-insurer must provide the first copy of a claim file free of charge. Upon receipt of a subsequent written request, the self-insurer must provide any material not previously supplied free of charge. The self-insurer may charge the worker or any representative a reasonable fee for any material previously supplied.
(9) What must a self-insurer do when it terminates time loss?
No later than the date of time loss termination, a self-insurer must notify the worker in writing of the reasons for time loss termination. If termination is based on a release to work not received directly from the worker, attach a copy of the release to the notice.
[Statutory Authority: RCW 51.04.020, 51.14.020, 51.32.190, 51.14.090, and 51.14.095. WSR 06-06-066, § 296-15-420, filed 2/28/06, effective 4/1/06. Statutory Authority: RCW 51.32.190(6), 51.32.055 (8)(a) and (9)(a). WSR 98-24-121, § 296-15-420, filed 12/2/98, effective 1/2/99.]




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