Washington > Workers Comp > Independent Medical Exam (IME)
IME Provider Account Application F245-046-000 - Washington
| IME Provider Account Application Form. This is a Washington form and can be used in Independent Medical Exam (IME) Workers Comp . |
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STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES PO Box 44261 Olympia, Washington 98504-4261 Dear Provider: Attached is the Provider Application and Agreement form necessary to obtain an Independent Medical Examiner (IME) provider account number with the Washington State Department of Labor and Industries Industrial Insurance Program. For group practices, each provider who will be providing services to injured workers must complete and sign the "Provider Agreement" section. The department will purchase only covered services, provided by covered professionals. Coverage information is contained in the Department of Labor and Industries publication"Medical Aid Rules and Fee Schedules," form number F245-094-000. To obtain a copy, call the Provider Hotline at 1-800-848-0811, or fill out and mail the L&I Medical Forms Request card included in your packet information. A completed Form W-9 is required as part of the applcation process ti o ensure proper reporting to the Internal Revenue Service (IRS). We have enclosed a blank Form W-9 for your convenience. If you have questions on the Form W-9, please contact the IRS or your tax consultant. Please carefully complete the IME rovider Application/Agreement using the attached instructions. We will not process an incomplete application. Please be sure to: 1) Complete the form and sign the Provider Agreement. 2) Include your mailing address on the last page, so we may notify you when we have received your application 3) Submit your completed Form W-9. 4) Submit a copy of your professional license for each state where you will be conducting IMEs, and a copy of the other documents requested on the application. If you, or your company will be billing the departmelectroent nically please contact the Electronic Billing Unit at 360-902-6511 for information regarding electronic billing. Once your IME provider account number has been established, you wi receive informll ation regarding rules, fees, billing forms, options for electronic and paper billing, and instructions. If you wish to receive this information prior to signing the forms, or if you have questions about the application, please call the Provider Accounts Section at 360-902-5140. Sincerely, Provider Accounts Enclosures F245-046-000 IME provider account application and notice 12-03 <<<<<<<<<********>>>>>>>>>>>>> 2 IME PROVIDER APPLICATION & AGREEMENT The Industrial Insurance Program is authorized by Washington State law, Title 51 Revised Code of Washington (RCW), and is admistered inby the Department of Labor and Industries. IME services are provided according to Title 51 RCW, Washington Administrative Code (WAC) Chapter 296-23, and policies adopted by the department, including medical coverage decisions. To qualify for payment, an IME provider must have an active IME provider account number assigned by the department.To receive a provider account number, the provider must submit an IME Provider Application to the department, including all required supporting information and a signed "IME Provider Agreement." For group practices, a separate IME Provider Application/Agreement is required for each provider who will be providing services to injured workers. The following information must be submitted with the IME Provider Application: current copy of the providers professional license; copy of curriculum vitae; copy of current board certifications, if applicable; (a letter from board confirming certification is acceptable) copy of fellowship certificate(s) if applicable; signed and dated Provider Agreement; completed Form W-9; and IME Provider Exam Site form. Issuance of a provider number does not guarantee that all services billed by a provider will be paid by the department. Payments will be made according to the departments "Medical Aid Rules and Fee Schedules" as updated annually and according to department policy. The department will purchase only covered services, provided by covered professionals. The provider agrees: 1. To meet and maintain all applicable state and/or federal licensing or certification requirements to assure the department of the providers qualifications to perform services. 2. To comply with Washington State Law Title 51 RCW, Washington mAdinistrative Code (WAC), including but not limited to, Chapters 296-23 and policies adopted by the department, including fee schedules and medical coverage decisions. 3. That providing services to an injured or ill worker who is covered under the departmentsrisdiction, constitutes acceptance juof the requirements of Title 51 RCW, and the WACs, including but limnotited to, Chapters 296-20, 296-21, 296-23, and 296-23A, and policies adopted by the department, including fee schedules and medical coverage decisions. 4. To accept the departments or self-insured employers or nssured emelf-iployers payment as sole and complete remuneration for services provided to the worker as required by Washington State law. The provider agrees not to bill a worker for: a) services covered by the industrial insurance program which are related to the industrial injury or occupational disease; b) the difference between the billed and paid charges. In the event a provider believes additional funds are due, the provider may submit a Providers Request for Adjustment Form to the department for consideration in accordance with the instructions contained on the Remittance Advice. 5. That if the provider receives payment from the department or self-insurer in error or in excess of the amount properly due under the applicable rules and policies, the provider will promptly return to the department or self-insurer any excess monies received. The department may audit the providers records to determine compliance with the rules and regulations of the department as provided in Washington State law. 6. To maintain documentation and records for a minimum of five ys to support the ear services and levels of services billed. The provider agrees that these records and supportive mrials will be mateade available to the department upon request as provided in Washington State law. 7. To notify the department immediately of yan changes to information in this application or provider status (e.g., federal tax identification number, ownership, incorporation, address, etc.). A change in ownership or federal tax ID number may require a new IME provider account number. If a new IME provider account number is assigned, providers who bill electronically must also submit an
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