Forms and Publications

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

This manual provides detailed instructions for providers on how to the bill the department using the CMS 1500.

Flyer: explains common errors on the Interpreter Services Appointment Record (ISAR). Explains to interpreters for injured workers how to avoid problems when completing the ISAR that could delay bill payment for services.

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)

Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).

General billing information for those providers that bill the department.

This form is used to request repairs to hearing aid or to request the purchase of durable medical equipment (DME).

This billing manual provides instructions to home health providers on how to bill the department.

This manual provides billing instructions for those billing hospital services to the department.

This form is used by interpreters to verify to L&I (state fund and Crime Victims claims) and self-insured employers for interpretive service at medical or vocational visits.

When ordering, there is a limit of 4 pads, or 100 copies total.

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. Find a medical examiner.

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I's Provider Express Billing.

This billing manual is for those providers billing for miscellaneous services.

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.

This billing manual provides detailed instructions for pharmacies on the correct way to the bill the department for services provided to injured workers.

This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)

This form is used by physical, occupational, and massage therapist to request additional visits for injured workers.

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).

This form is used to pharmacies to request authorizations for prescriptions from the Preferred Drug Line (PDL).

This is a general billing manual for all providers billing the department for medical services.

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.

Flyer or small poster for administrative staff for health-care and vocational providers: lists the most frequently used procedure codes and fees. The back highlights the most popular or frequently used web pages for providers and their staff. Provides tips for speeding up authorizations and for billing self-insured employers.

Used to Refund Money to L&I to correct your account REFUND NOTIFICATION

This billing manual tells you how to bill the department for retraining and job modification services provided to injured workers.

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.

Used to bill L&I for reimbursement of home nursing services.

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.

Use this form to register or update your taxpayer ID number or register and make changes to your direct deposit information.

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.

Washington Practitioner Application is used by providers applying for the L&I Provider Network.