Providers outside the United States use this request when a service for a worker with a Washington workers' compensation claim needs prior authorization. Most out-of-country professional services require it, and all surgeries abroad go through utilization review. The provider gives the diagnosis, side of body, procedure description, expected cost, studies done, assistants, and estimated procedure and inpatient dates, with supporting reports attached.
The out-of-country treating provider completes the provider, patient and medical information sections, including the L&I provider identification number and a staff contact. L&I completes the authorization response.
Download the current version from the source each time; forms change without notice.
Preauthorization Request for Medical Services For Out of Country Providers
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For many services, yes. L&I's out-of-country payment policy says most professional services require prior authorization and all surgeries outside the United States require utilization review. Use this form on State Fund claims; on self-insured claims, ask the employer or its third-party administrator.
Yes. L&I directs Spanish-speaking providers to F245-429-999. For other languages, providers use the English F245-429-000 or contact the insurer for help, and L&I's policy makes the insurer responsible for translating out-of-country documentation into English.