Claims Adjudication Tune-Up (CAT-U)
March 2026 Edition
Welcome to Self-Insurance’s (SI) Claims Adjudication Tune-Up (CAT-U) newsletter. This is where the Washington State Department of Labor & Industries (L&I) shares best practices and information, as well as highlight opportunities for improvement. The focus of this month’s edition of CAT-U is contention of conditions.
News you can use
Washington Administrative Code 296-15-425: Communicating to injured workers during the course of the claim
“(3) When must a department-developed template be completed and sent to the
worker? Within five days of a claims administrator taking action on a claim
involving:
(c) Acceptance or denial of a condition contended under the claim…
(4)(c) If no dispute is received, then the department will not issue an order…”
Take away: Timely communication is important. If there’s contention for a new condition with a request for treatment, it may make sense to initially deny the treatment request with an explanation that the condition has not yet been accepted. If the condition is later accepted, you would issue the accept newly contended condition template, and revisit authorization for the previously denied treatment.
Medical aid rules (MARFS) Chapter 3: Attending providers
Attending provider (AP) responsibilities: “AP on the claim is responsible for managing the worker’s conditions and progress…reporting and addressing restrictions to recovery, including unrelated conditions…” (Page 6)
Consultation documentation requirements: “…the consultation report must include…Complete diagnosis of all pathological conditions as a result of the injury, and any other preexisting conditions that may have been aggravated by the injury or may retard recovery” (Pages 25-26)
Claim impact: Attending providers might report on unrelated conditions in their chart notes, along with other information about the worker’s general health. This does not always mean that the worker or AP is asserting the condition should be accepted on the claim. Consultation reports may also mention many conditions, including some related and some not. Before accepting or denying a condition based on a consulting physician report, confirm that the worker and AP are contending the condition should be accepted under the claim.
Contention may be very plain: a request for treatment for a new condition, or the worker’s provider asking for a condition to be accepted under the claim. Or it may not be as clear, such as a mention in Physical Therapy notes of a condition impacting recovery, or a billing statement with several conditions. There may be ongoing mention of a condition in chart notes. It may be part of a differential diagnosis; a listing of conditions that are suspected by the provider, but don’t yet meet the threshold for diagnosis in the worker’s case.
Sending a template accepting or denying a condition that’s not actually being contended can confuse workers and providers. Review the medical record carefully, if you are not certain whether a condition has been diagnosed and is being contended as related. Is the condition impacting the worker’s recovery? Is the diagnosis clear, or still uncertain? In these cases, you may want to contact the worker or provider and ask what they’re contending before making a decision.
Trainer trivia
Question: Who won the first March Madness tournament?
More reading/resources
Self-Insurance Claim Adjudication Guidelines: medical treatment and claim validity chapters
Reminders/tips from the SI teams
When in doubt, ask! If you’re not sure about a condition’s diagnosis or whether it’s being contended, call or write to the provider or the worker. If you know you’ll need time to make a decision, communicate that as well. Contact the worker and their provider and let them know that the decision will take time.
For more information, send an email to the self-insurance trainer box.
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