Chiropractic insurance billing in Washington.

NO state-mandated auto/PIP medical fee schedule. Insurers reimburse on a ‘reasonable and customary’ (UCR) basis. Per Schiff v. Liberty Mutual (Wash. 2024), insurers may use a charge database (e.g., FAIR Health 80th percentile by geographic area) to set reasonableness and reduce bills above that threshold, and that database approach can satisfy the insurer’s reasonable-investigation duty without individualized bill-by-bill review; the court held this does not violate the PIP statutes or the Consumer Protection Act.

No fixed auto-specific ‘pay within X days’ deadline. WA’s unfair-claims-settlement rules (WAC 284-30-330 et seq.) require insurers to acknowledge claim communications reasonably promptly, adopt reasonable standards for prompt investigation, and attempt in good faith to effectuate prompt, fair settlement once liability is reasonably clear.

WAC 284-30-370 directs insurers to complete a claim investigation within ~30 days of notice unless it reasonably cannot be done in that time. WAC 284-30-395 specifically governs PIP: before denying, limiting, or terminating PIP medical/hospital benefits the insurer must give a written explanation stating the true and actual reason; a generic ‘not reasonable or necessary’ is expressly insufficient, and there are only four permissible grounds (not reasonable, not necessary, not accident-related, or beyond the 3-year window).

Insurance Fair Conduct Act (IFCA), RCW 48.30.015: a FIRST-PARTY claimant (e.g., the insured under PIP/UM/UIM) who is UNREASONABLY DENIED a claim for coverage or payment of benefits may sue for actual damages plus costs and reasonable attorney fees, and the court MAY increase the award up to THREE TIMES actual damages.

Important limits: under Perez-Crisantos v. State Farm (Wash. 2017), IFCA requires an actual unreasonable denial of coverage/benefits — a bare regulatory violation alone is not enough to create the cause of action; and a first-party claimant must generally give 20 days’ written pre-suit notice to the insurer and the Insurance Commissioner before filing.

WA also recognizes common-law insurance bad faith. These remedies run to the insured/first-party claimant (and any assignee), not directly to a non-assigned provider, but they are the leverage behind PIP disputes.

Because there is no fee schedule, a non-contracted provider is generally not contractually bound to accept the insurer’s UCR figure as payment in full, and a PIP reduction/exhaustion does not by itself erase the underlying charge — the balance can, depending on the facts, still be pursued from the patient and ultimately through the patient’s third-party/at-fault recovery, often via a perfected medical lien (RCW ch. 60.44, which limits a provider lien to a capped share of the recovery).

Sound practice is to dispute UCR-based reductions with a written reduction appeal: attach chart notes/medical records documenting that care was reasonable, necessary, and accident-related, and cite the WAC 284-30-395 requirement for a true, specific written reason and the four-grounds limit.

Post-Schiff, the database/80th-percentile reduction itself is much harder to defeat outright (a database approach can satisfy the insurer’s investigation duty), so the strongest appeals focus on documenting medical necessity and accident-relatedness and on holding the insurer to the written-true-reason standard, rather than arguing the insurer lacks any basis to reduce.

YES — L&I sets the Medical Aid Rules (WAC ch. 296-20) and Fee Schedules (MARFS), updated annually (e.g., 2025 and 2026 editions published). MARFS defines maximum allowable fees, billing codes, and payment policies, including chiropractic/physical-medicine content.

The fees are maximums: the department or self-insurer pays the lesser of the billed charge or the MARFS maximum allowable. Applies to BOTH state-fund and self-insured (and TPA-administered) claims. The provider must accept payment as payment in full; balance-billing the injured worker for the difference is prohibited.

Providers generally must be enrolled as L&I providers to bill. Bills follow MARFS coding/policy requirements; chart notes and documentation supporting medical necessity are expected and are commonly requested to substantiate care and to support reconsideration/appeal of a reduced or denied bill.

For self-insured claims, bills go to the self-insured employer or its TPA (not directly to L&I), but under the same MARFS rules and maximum fees.

L&I and self-insured payers process bills under MARFS payment policies. The deadline a chiropractor most needs to watch is the PROVIDER’s own appeal window: a medical provider generally has only ~20 DAYS to appeal/protest a billing decision that reduces payment or demands repayment of sums already paid — far shorter than the 60-day window that applies to general claim decisions.

Missing it generally makes the decision final.

To challenge a payment/claim decision: first request reconsideration/protest to L&I (or, for self-insured claims, work through the self-insured payer), which can reopen and reconsider; if unresolved, appeal to the Board of Industrial Insurance Appeals (BIIA), an independent body that notifies L&I, allows reconsideration, and otherwise schedules a hearing.

General claim/payment decisions carry a 60-day appeal deadline; for medical PROVIDERS, a billing reduction or repayment-demand decision carries a much shorter ~20-day deadline. Appeals may be filed online, by mail, or in person (BIIA, PO Box 42401, Olympia, WA 98504-2401).

summary: Washington L&I does NOT accept the standard national CPT chiropractic manipulative treatment (CMT) codes. L&I runs its own Medical Aid Rules and Fee Schedules (MARFS) and requires chiropractors to bill L&I-specific local codes for the core chiropractic visit and for physical-medicine modalities. notCovered: [“CPT CMT codes 98940-98943 are NOT covered.

Verbatim from MARFS: ‘CPT chiropractic manipulative treatment (CMT) codes 98940-98943 aren’t covered.'”, “CPT physical medicine codes 97001-97799 are NOT payable to chiropractic physicians. Verbatim: ‘CPT physical medicine codes (97001-97799) aren’t payable to chiropractic physicians.'”, ‘Chiropractic manipulation/manual therapy for chronic migraine or chronic tension-type headache is not a covered benefit.’, ‘Dynamic Spinal Visualization / videofluoroscopy (code 76496) and audio-only (modifier -93) chiropractic evaluation/treatment are not covered.’] localCodes: [{‘code’: ‘2050A’, ‘name’: ‘Chiropractic care visit, Level 1 (straightforward clinical decision-making)’, ‘note’: ‘Bundles professional management AND the manipulation/adjustment into one per-visit code.’}, {‘code’: ‘2051A’, ‘name’: ‘Chiropractic care visit, Level 2 (low complexity clinical decision-making)’}, {‘code’: ‘2052A’, ‘name’: ‘Chiropractic care visit, Level 3 (moderate complexity clinical decision-making)’}, {‘code’: ‘1044M’, ‘name’: ‘Physical medicine modalities/procedures billed by a non-physical-medicine attending provider (replaces CPT 97001-97799 for chiropractors)’, ‘limit’: ‘Only 1 unit payable per day; limited to 6 units per claim, after which the worker must be referred to a PT/OT or physiatrist (WAC 296-21-290).’}, {‘code’: ‘1040M’, ‘name’: “Completion of the State Fund Report of Accident (ROA) or the Self-Insurer’s Provider’s Initial Report (PIR)”}] fees:

Per L&I’s Quick Reference Fee Card (effective July 1, 2025 – June 30, 2026): chiropractic care 2050A-2052A range = $50.59-$78.97; physical medicine 1044M = $52.84; Report of Accident 1040M = $46.47. Fees update every July 1. levelSelection:

Unlike national CPT CMT (which scales by number of spinal regions), L&I’s 2050A-2052A scale by clinical decision-making COMPLEXITY, similar to an evaluation and management (E/M) code. L&I instructs providers to document ‘the clinical decision-making complexity, not just the number of spinal regions and/or extremities.’ The FY2024 MARFS Ch. 7 grid set rough thresholds by condition complexity, body regions treated (up to 2 / up to 3-4 / 5 or more) and face-to-face time (up to 15 min / 15-25 min / over 25 min); a December 2025 update (MARFS Ch. 20) restated level selection as a five-factor grid (severity, body regions, time, co-morbidities, treatment plan) where the level equals the highest 3 of 5 factors.

Confirm the current grid before relying on exact minute thresholds, as they were revised between the 2024 and 2026 editions. cptStillAccepted: [‘E/M office visits 99202-99215 (new and established patients) are payable, but a new-patient E/M is payable only once at the initial visit, and only ONE chiropractic care visit per day is payable.’, ‘Diagnostic X-ray services billed using standard CPT radiology codes (initial medically necessary X-rays need no prior auth; subsequent X-rays do).’, ‘Consultations (CPT office consultation codes) only by L&I-approved chiropractic consultants, requiring prior notification per WAC 296-23-195.’, ‘IME / impairment-rating codes only by L&I-approved examiners.’] modifiers: [‘Modifier -25 (significant, separately identifiable E/M) is REQUIRED when an E/M code is billed on the same day as a chiropractic care visit (2050A/2051A/2052A), and the chart must document both services separately.

Time/treatment that is part of the chiropractic care visit cannot be counted toward the E/M level.’, ‘Modifier -22 is NOT payable with E/M office visit codes or chiropractic care services.’, ‘Modifier -GT indicates telehealth; audio-only (-93) is not payable for chiropractic evaluation/treatment.’] providerAccount:

A chiropractor cannot bill at all without an active L&I provider account number (NPI must be registered with L&I; Washington-based DCs must enroll in L&I’s Medical Provider Network to treat injured workers beyond the initial/ER visit).

Accounts auto-terminate after 18 months of billing inactivity.

summary: Prior authorization is required for all conservative care, including chiropractic, when billing for more than 20 office visits OR for visits occurring more than 60 days after the first date you treat the worker, whichever occurs first. cap:

More than 20 office visits, or visits more than 60 days after the first date of treatment, whichever occurs first (WAC 296-20-03001; WAC 296-20-030). WAC 296-20-03001 states authorization is required for ‘office calls in excess of the first 20 visits or 60 days whichever occurs first.’ subLimits: [‘Only one chiropractic care visit per day is payable.’, ‘Physical-medicine local code 1044M is limited to 6 units per claim (1 unit/day).’, ‘Extra-spinal/extremity manipulations are not billed separately; all extremities count as one body region.’] authorizationProcess:

To continue beyond the cap, the provider must obtain prior authorization (State Fund: Claim & Account Center / Provider Hotline 1-800-848-0811; self-insured: the self-insured employer or its TPA). The request must state the diagnosis (ICD codes), its relationship to the industrial injury, the proposed treatment program/components and procedure codes, expected prognosis, and an estimated treatment-conclusion date.

Continued conservative care is also gated by a consultation to determine whether ongoing care is appropriate (L&I references ’60 and 120 day consultations’); a DC consultant enrolled in L&I’s Chiropractic Consultant Program may render a second opinion on conservative musculoskeletal care.

Treatment must be curative or rehabilitative, not maintenance care (WAC 296-20-03002). reporting: Treatment reports must be filed at 60-day intervals, including the number of office visits to date (WAC 296-20-030). Detailed reporting/documentation rules are in WAC 296-20-06101; notes should follow the SOAPER format.

Each visit must document all body regions treated. attendingProvider: A doctor of chiropractic MAY serve as the attending (or concurrent) provider for injured workers whose accepted condition is musculoskeletal/neuromusculoskeletal (spine and/or extremity).

There is no fixed maximum number of days a DC may remain attending provider; the DC remains AP only so long as the accepted condition is within chiropractic scope. Care must transfer to an appropriate provider if the claim involves conditions outside chiropractic scope (e.g., surgery).

Washington Apple Health (Medicaid) covers chiropractic for members under age 21, and a more recent adult benefit added limited chiropractic for those 21 and older. Coverage is typically restricted to medically necessary spinal manipulation, and managed-care plans often apply combined annual visit caps across chiropractic, acupuncture, and massage.

Under RCW 18.25, Washington DCs may generally perform exams and diagnostic X-rays, deliver spinal manipulation/adjustments, and provide physiological therapeutic procedures such as heat, cold, traction, exercise, and massage. The statutory scope notably excludes therapies using sound (ultrasound), diathermy, or electricity, as well as prescribing drugs.