Claims Kit

Physician Selection RCW 51.36.010

For the initial office or emergency room visit only, the employee may choose any health care provider who is qualified to treat their injury. For any additional or ongoing care, the employee must be treated by a provider who is a part of the L&I Medical Provider Network. If the employees regular provider is not in the network and does not want to enroll, the employee must transfer to a network provider

Reporting of Claim by Employer  51.28.010 (1)  51.28.025

An employer who has notice or knowledge of an injury or occupational disease of their employee and who has received treatment from a physician, or has been hospitalized, disabled from work, or who has died must immediately report this information to the Department. 

A workplace fatality or in-patient hospitalization of any employee must be reported to L&I within 8 hours of the incident. Any non-hospitalized amputation or loss of an eye(s) must be reported within 24 hours of the incident. Note: This applies to all employers with workers working in Washington no matter what industry they work in and regardless of workers’ compensation coverage

Penalties for Late Reporting RCW 51.28.025  

An employer found to have engaged in claim suppression is subject to a penalty of at least $250, not to exceed $2,500, for each offense.

Questions About Workers' Compensation Coverage and Coronavirus (COVID-19)

Q:Can COVID-19 ever be allowed as a work-related condition?

A:Under certain circumstances, claims from health care providers and first responders involving COVID-19 may be allowed. Other claims that meet certain criteria for exposure will be considered on a case-by-case basis.

In most cases, exposure and/or contraction of COVID-19 is not considered to be an allowable, work-related condition.

Q: When to file a claim

A: The Industrial Insurance Act allows for treatment of COVID-19 when work-related activity has resulted in probable exposure to the virus and certain criteria are met. In these cases, the worker's occupation must have a greater likelihood of contracting the disease because of the job (examples include first responders or health care workers). There must also be a documented or probable work-related exposure, and an employee/employer relationship.

Q: When will a claim likely be denied?

A: When the contraction of COVID-19 is incidental to the workplace or common to all employment (such as an office worker who contracts the condition from a fellow employee), a claim for exposure to and contraction of the disease will be denied.

Q: How can I file a COVID-19 claim?

A: For workers

• Online via our FileFast tool.
• By phone: 1-877-561-3453 (FILE).
• At your doctor's office (if you complete the Report of Accident at your doctor's office, the doctor files the form for you).

Filing a worker's compensation claim: Exposure vs. contraction of COVID-19

Workers exposed to COVID-19 must submit the appropriate accident report form before the insurer (L&I or the self-insured employer) can pay for treatment or time-loss benefits. The same is true if the worker is unable to work during the quarantine period or is ill from the virus.

While in most cases, L&I expects to receive claims for contraction of COVID-19, the Industrial Insurance Act allows the insurer to pay for testing before someone is ill when there's been a documented, work-related exposure.

If the diagnosed condition on the original accident report form is contraction of COVID-19 and the three criteria under "when to file a claim" are satisfied, the claim will be allowed and treatment authorized.

When a claim is filed for probable exposure and the criteria under "when to file a claim" are satisfied, the claim will be allowed for the quarantine period whether or not the worker actually contracted COVID-19.

Quarantine

L&I will accept claims of health care workers and first responders who are quarantined after COVID-19 exposure on the job. Other quarantine claims will be looked at on a case-by-case basis.

For an exposure claim to be considered, it must meet the criteria AND the worker must have been quarantined by a public health officer or physician because of that exposure.

Self-Insurance Coronavirus Frequently Asked Questions

Q: If a self-insured employer pays a worker’s wages while the worker is quarantined due to a work-related exposure, is the employer required to provide a SIF-2 form and assistance with filing a claim?

A: No. For an exposure-related quarantine that does not result in a positive COVID-19 diagnosis, a SIF-2 form does not have to be completed as long as the employer continues to pay their regular wages.

Q: If a self-insured employer receives a Physician’s Initial Report (PIR) for a quarantined worker who is not being tested for coronavirus and is still paid their regular wages, are they required to provide a SIF-2 form and assistance with filing a claim?

A: Yes. If a PIR is received, a SIF-2 form should be filed. Allowance should be requested if the criteria are met (see Workers’ Compensation Coverage and Coronavirus Common Questions).

Q: If a self-insured employer receives a PIR for a quarantined worker and coronavirus testing (or results) are pending, can the PIR/SIF-2 form be held until there are test results?

A: No. If an employer receives a PIR, a SIF-2 form should be filed requesting allowance if the allowance criteria are met. This is an allowable claim for the quarantine period even if the worker tests negative and the employer is paying the worker their regular wages.

Q: If a worker is diagnosed with COVID-19 and the allowance criteria are met, should a claim be submitted for allowance?

A: Yes. However, if a worker is diagnosed with COVID-19 and the employer or third-party administrator (TPA) believe the criteria for allowance are not met, a claim should be submitted with a request for denial.

Q: If a self-insured employer pays a worker’s wages while the worker is quarantined and tested for COVID-19, and the worker receives negative test results, should a claim be submitted for denial?

A: No. If the employer paid the worker their regular salary during the quarantine period and the worker receives negative test results, no further action is needed.

Q: If a self-insured employer doesn’t pay a worker’s wages while the worker is quarantined due to a work-related exposure, is the employer required to pay time-loss for the quarantine period?

A: Yes. If the employer does not pay the worker their regular salary, the employer must pay time-loss to the worker for the quarantine period, up to 14 days. And, the employer is required to provide a SIF-2 form and assistance with filing a claim.

Q: If a worker doesn’t meet the criteria for work-related exposure, is the self-insured employer required to pay the worker time-loss or their regular salary during the quarantine period?

1. No. If the exposure is not work-related and a worker is quarantined, then the employer is not required to pay time-loss to the worker; however, the employer may consider allowing the use of other paid leave to promote health and safety.

Q: Are COVID-19 claims considered an injury or occupational disease?

A: COVID-19 claims are considered occupational disease exposures. The date of manifestation (DOM) is the first day of quarantine or the diagnosis date, whichever comes first.

Q: In the Workers’ Compensation Coverage and Coronavirus Common Questions, a worker must be quarantined by a public health officer or physician. As a self-insured employer, I’m having trouble obtaining that documentation. What should I do?

A: Benefits for the 14-day quarantine period should be paid without delay. Documentation from a public health officer or physician may be obtained after payment has been made. If a worker self-quarantines, and during the 14-day quarantine period the worker is informed by a public health official or physician that the quarantine was appropriate, the worker is eligible to receive compensation for the entire quarantine period. As with all wage replacement benefits under the Industrial Insurance Act, the first three days are not paid unless the worker is medically required to remain off work on the 14^th day following exposure.

Questions About Self-Insurance and Coronavirus (COVID-19)

If a self-insured employer pays an employee's wages while the individual is quarantined due to a work-related exposure, is the employer required to provide a Self-Insurance Form 2 (SIF-2 form) and assistance with filing a claim?

No. For an exposure-related quarantine that does not result in a positive coronavirus diagnosis, a SIF-2 form does not have to be completed as long as the employer continues to pay their regular wages.

If a self-insured employer receives a Physician's Initial Report (PIR) for a quarantined employee who is not being tested for coronavirus and is still paid their regular wages, are they required to provide a SIF-2 form and assistance with filing a claim?

Yes. If a PIR is received, a SIF-2 form should be filed. You should request for the claim to be allowed if it meets the criteria (see Workers' Compensation Coverage and Coronavirus Common Questions).

If a self-insured employer receives a PIR for a quarantined employee and coronavirus testing (or results) is pending, can the PIR/SIF-2 form be held until there are test results?

No. If an employer receives a PIR, a SIF-2 form should be filed requesting the claim be allowed if it meets the criteria. This is an allowable claim for the quarantine period even if the employee tests negative and the employer is paying the employee their regular wages. If a employee is diagnosed with coronavirus and the employer or third-party administrator (TPA) believes the criteria for allowance are not met, the claim should be submitted with a request for denial.

If a self-insured employer pays an employee's wages while the employee is quarantined and tested for coronavirus, and the employee receives negative test results, should a claim be submitted for denial?

No. If the employer paid the employee their regular salary during the quarantine period and the worker receives negative test results, no further action is needed.

As a self-insured employer, we have protocol for exposures to the coronavirus that were put in place by a physician. If we pay benefits to an employee during the 14-day quarantine period based on that protocol, but the employee never actually sees a medical provider, will L&I object?

For an employee who never actually contracted the coronavirus, you can just state "employee quarantined per medical protocol," and attach a copy of that protocol.

If we pay benefits based on medical protocol, do we still need a Provider's Initial Report (PIR) from an attending provider to allow and close the claim?

If an employee follows medical protocol provided by a physician and either recovers or tests negative for the coronavirus and never seeks additional treatment, the self-insurer may request that a claim be allowed or closed based on the protocol. A copy of that protocol should be attached to the request.

If a self-insurer wants to have an employee seen by a medical provider (in person or by telehealth) before allowing or closing a claim, the insurer may direct the employee to make an appointment with a provider of the employee's choice. The employee must be given an appropriate time period for that to happen. We will not deny claims for the absence of a medical exam without confirmation that the employee was directed to seek treatment and given time for that to happen.

Are coronavirus-related claims considered an injury or occupational disease?

Coronavirus claims are considered occupational disease exposures. The first day of quarantine is the date of manifestation (DOM) or the diagnosis date, whichever comes first.

Emergency (CR-103E) - Public Health Emergency Reporting and Notification Requirements for Infectious and Contagious Diseases and Voluntary Use of Personal Protective Equipment

Brief Description:The Department of Labor & Industries (L&I) continues to respond to 2021 legislation establishing employer requirements during a public health emergency for infectious and contagious diseases. The employer requirements are under Substitute Senate Bill 5254 (SSB 5254), codified as RCW 49.17.485, regarding voluntary use of personal protective equipment (PPE), and Engrossed Substitute Senate Bill 5115 (ESSB 5115), also known as the Health Emergency Labor Standards Act (HELSA) and codified as RCW 49.17.062 and RCW 49.17.064.

The emergency rule maintains requirements under new sections of chapter 296-62 WAC for when there is a public health emergency for an infectious or contagious disease and as such, the requirements are applicable to COVID-19.

Under the emergency rule:

• Employers with more than 50 covered employees at a workplace or worksite are required to report infectious or contagious disease outbreaks to L&I;
• Employees are not required to disclose any medical condition or diagnosis to their employer;
• Several definitions were added and/or simplified for implementation;
• Non-healthcare employers, are required to notify employees, as well as their union representative (if any), in writing of potential exposures within one business day;
• Employees and contractors must be permitted to voluntarily use personal protective equipment.

In addition, this emergency rule now applies notification requirements to health care facilities as defined in RCW 9A.50.010.

• Employers of health care facilities must notify any employee with known or suspected high-risk exposure to the infectious or contagious disease within 24 hours. With employee authorization, notification must also be sent to the employee’s union representative (if any) within 24 hours.
• Period of transmission/isolation requirements have been simplified.
• Requirements for how employees are notified of potential high risk exposure are clarified.

A CR-101 Preproposal Statement of Inquiry was filed on May 13, 2021 (WSR 21-11-051) and initiated the permanent rulemaking process for rules related to infectious diseases, which will include requirements for outbreaks subject to a public health emergency under a national or state declared state of emergency. This emergency rule supersedes WSR 22-09-003 filed on April 6, 2022.

Effective date: August 4, 2022
Expiration date: December 2, 2022

The links below provide additional information about this rulemaking:
CR-103 Emergency Adoption

If a self-insured employer pays an employee's wages while the employee is quarantined and tested for coronavirus, and the employee receives negative test results, should a claim be submitted for denial?

No. If the employer paid the employee their regular salary during the quarantine period and the worker receives negative test results, no further action is needed.

If a self-insured employer doesn't pay an employee's wages while the employee is quarantined due to a work-related exposure, is the employer required to pay time-loss benefits for the quarantine period?

Yes. If the employer does not pay the employee their regular salary, the employer must pay time-loss benefits to the employee for the quarantine period, up to 14 days. And, the employer is required to provide a SIF-2 form and assistance with filing a claim.

If an employee doesn't meet the criteria for work-related exposure, is the self-insured employer required to pay the employee time-loss benefits or their regular salary during the quarantine period?

No. If the exposure is not work-related and an employee is quarantined, then the employer is not required to pay time-loss benefits or regular salary to the employee; however, the employer may consider allowing the use of other paid leave to promote health and safety.

The Self-Insurance Medical Bill Electronic Data Interchange (EDI) is now accepting the new COVID-19 Diagnosis Code, U0.71. The EDI will accept any bill that includes this diagnosis code without any disruption. No additional action is required from our customers.

Posting Requirements

Employers are legally required to display 3 free posters in their workplace to inform employees of their rights and responsibilities. 

Certificate of coverage required RCW 51.04.120

Employers are required to obtain a certificate of insurance coverage and post it conspicuously in their place of business. They must have a separate certificate of coverage in each business location they operate. 

L&I will send three posters that inform employees of their rights and responsibilities as workers. They must be displayed where employees can see them 

Does a construction company have to post the posters at every job site or just in the construction office?

The key consideration is where the employees report for work. If your employees report to a central office, posting in the office is fine. If they report to a job shack, post them there. You may want to do both as the posters are free. You are not required to post them in a truck.

As an employer, you are required to make the posters available to your employees where they can see and read them.

If I the employer has one or more employees in Washington State who work from their home or vehicle, do they have to post the posters in their home or vehicle?

No. As the employer, you are required to make the posters available to your employees where they can see and read them. To comply with this requirement for employees working from their home or vehicle, you may:

Send each employee a set of posters. You can order them at no cost by visiting Lni.wa.gov/Posters. You may want to document that you sent the posters to your employees.

AND/OR

Send each employee an email with a link to Lni.wa.gov/Posters. Instruct your employees to read the posters and print them for their records. They do not have to post them in their home or vehicle.

1.  Notice to Employees — If a Job Injury Occurs  F242-191-909 
2.  Job Safety and Health Law (F416-081-909).  
3. Your Rights as a Worker ( F700-074-000). F700-074-999 SP