Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2050 - Prior authorization processes

Current through Register Vol. 24-14, July 15, 2024
(1) This section applies to health benefit
				plans as defined in
				RCW
				 48.43.005, contracts for limited health care
				services as defined in
				RCW
				 48.44.035, and stand-alone dental and
				standalone vision plans. This section applies to plans issued or renewed on or
				after January 1, 2018. Unless stated otherwise, this section does not apply to
				prescription drug services.
(2) A
				carrier or its designated or contracted representative must maintain a
				documented prior authorization program description and use evidence-based
				clinical review criteria. A carrier or its designated or contracted
				representative must make determinations in accordance with the carrier's
				current clinical review criteria and use the medical necessity definition
				stated in the enrollee's plan. The prior authorization program must include a
				method for reviewing and updating clinical review criteria. A carrier is
				obligated to ensure compliance with prior authorization requirements, even if
				they use a third-party contractor. A carrier is not exempt from these
				requirements because it relied upon a third-party vendor or subcontracting
				arrangement for its prior authorization program. A carrier or its designated or
				contracted representative is not required to use medical evidence or standards
				in its prior authorization of religious nonmedical treatment or religious
				nonmedical nursing care.
(3) A
				prior authorization program must meet standards set forth by a national
				accreditation organization including, but not limited to, National Committee
				for Quality Assurance (NCQA), URAC, Joint Commission, and Accreditation
				Association for Ambulatory Health Care in addition to the requirements of this
				chapter. A prior authorization program must have staff who are properly
				qualified, trained, supervised, and supported by explicit written, current
				clinical review criteria and review procedures.
(4) Effective November 1, 2019, a carrier or
				its designated or contracted representative must have a current and accurate
				online prior authorization process. All parts of the process that utilize
				personally identifiable information must be accessed through a secure online
				process. The online process must be accessible to a participating provider and
				facility so that, prior to delivering a service, a provider and facility will
				have enough information to determine if a service is a benefit under the
				enrollee's plan and the information necessary to submit a complete prior
				authorization request. A carrier with an integrated delivery system is not
				required to comply with this subsection for the employees participating in the
				integrated delivery system. The online process must provide the information
				required for a provider or facility to determine for an enrollee's plan for a
				specific service:
(a) If a service is a
				benefit;
(b) If a prior
				authorization request is necessary;
(c) What, if any preservice requirements
				apply; and
(d) If a prior
				authorization request is necessary, the following information:
(i) The clinical review criteria used to
				evaluate the request; and
(ii) Any
				required documentation.