reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-030 - Application for certification as an IRO

Current through Register Vol. 24-14, July 15, 2024
(1) To be certified as an IRO under this
				chapter, an organization must make an application to the commissioner upon a
				form to be furnished by the commissioner as required under
				RCW
				 48.43.537 and submitted using the
				commissioner's online service. The application must include or be accompanied
				by the following:
(a) An attestation on the
				form required by the commissioner, signed by a company officer, certifying that
				all requirements within
				RCW
				 48.43.537 and this chapter will be
				met;
(b) Evidence of current
				accreditation from a nationally recognized private accrediting organization
				acceptable to the federal Department of Health and Human Services or Department
				of Labor for the federal external review process;
(i) Applicants shall authorize release of
				information from primary sources, including full reports of site visits,
				inspections, and audits; and
(ii)
				The commissioner may require the applicant to indicate which documents
				demonstrate compliance with specific Washington state certification
				requirements under this chapter.
(c) Other documentation including, but not
				limited to, legal and financial information, policies and procedures, and data
				that are pertinent to requirements of this chapter; and
(d) Any other pertinent information required
				by the commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-040 - Administrative processes and capabilities of IROs

Current through Register Vol. 24-14, July 15, 2024
(1) An IRO shall maintain written policies
				and procedures covering all aspects of review.
(2) An IRO shall ensure the confidentiality
				of medical records and other personal health information received for use in
				independent reviews, in accordance with applicable federal and state
				laws.
(3) An IRO shall have a
				quality assurance program that ensures the timeliness, quality of review, and
				communication of determinations to enrollees and carriers. The quality
				assurance program must ensure the qualifications, impartiality, and freedom
				from conflict of interest of the organization, its staff, and expert reviewers.
(a) The quality assurance program must
				include a written plan addressing scope and objectives, program organization,
				monitoring and oversight mechanisms, and evaluation and organizational
				improvement of IRO activities.
(b)
				Quality of reviews includes use of appropriate methods to match the case,
				confidentiality, and systematic evaluation of complaints for patterns or
				trends. Complaints must be recorded, including the nature of the complaint and
				the resolution. The commissioner may examine the complaint records.
(c) Organizational improvement efforts must
				include the implementation of action plans to improve or correct identified
				problems, and communication of the results of action plans to staff and
				reviewers.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-050 - Conflict of interest

Current through Register Vol. 24-14, July 15, 2024
(1) An IRO:
(a) Must not be a subsidiary of, or in any
				way owned or controlled by, a carrier or an association of health care
				providers or carriers;
(b) Shall
				provide information to the commissioner on its own organizational affiliations
				and potential conflicts of interest at the time of application and when
				material changes occur;
(c) Shall
				immediately turn down a case referred by the commissioner if accepting it would
				constitute an organizational conflict of interest; and
(d) Shall ensure that reviewers are free from
				any actual or potential conflict of interest in assigned cases.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-060 - Expert reviewers

Current through Register Vol. 24-14, July 15, 2024
(1) Each
				IRO shall maintain an adequate number and range of qualified expert reviewers
				in order to:
(a) Make determinations
				regarding the full range of independent review cases occurring in Washington
				state under
				RCW
				 48.43.535; and
(b) Meet timelines specified in WAC
				284-43A-070(3) including those for expedited review.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-070 - Independent review process

Current through Register Vol. 24-14, July 15, 2024
(1)
				Information for review.
(a) IROs shall, as
				necessary, request, accept, and consider the following information as relevant
				to a case:
(i) Information that the carrier
				is required to submit to the IRO under WAC 284-43A-140, including information
				identified in that section that is initially missing or incomplete as submitted
				by the carrier.
(ii) Other medical,
				scientific, and cost-effectiveness evidence which is relevant to the case. For
				the purposes of this section, medical, scientific, and cost-effectiveness
				evidence has the meaning defined in WAC 284-43A-010.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-080 - Criteria and considerations for independent review determinations

Current through Register Vol. 24-14, July 15, 2024
(1) General
				criteria and considerations.
(a)The
				determination must be consistent with the standards in
				RCW
				 48.43.537,
				48.43.535, and chapter 284-43A
				WAC.
(b) The expert reviewers from
				a certified IRO will make determinations regarding the medical necessity or
				appropriateness of, and the application of health plan coverage provisions to,
				health care services for an enrollee.
(c) The IRO shall ensure that determinations
				are consistent with the scope of covered benefits as outlined in the medical
				coverage agreement.
(i) Clinical reviewers
				may override the health plan's medical necessity or appropriateness standards
				only if the standards are determined upon review to be unreasonable or
				inconsistent with sound, evidence-based medical practice, or experimental or
				investigational treatment protocols.
(ii) Reviewers may make determinations about
				the application of general health plan coverage provisions to specific issues
				concerning health care services for an enrollee. For example, whether a
				specific service is excluded by more general benefit exclusion language may
				require independent interpretation.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-090 - Additional requirements for experimental or investigational treatment reviews

Current through Register Vol. 24-14, July 15, 2024
(1) In addition
				to the qualifications listed in WAC 284-43A-060(3) and (5), at least part of
				the clinical reviewers' relevant, recent clinical experience must have been
				obtained in the past three years.
(2) Each clinical reviewer shall consider the
				following information, if appropriate and available, in reaching an opinion:
(a) The enrollee's pertinent medical
				records;
(b) The attending
				physician or health care provider's recommendation;
(c) Consulting reports from appropriate
				health care providers and other documents submitted by the carrier, enrollee,
				or enrollee's authorized representative, or the enrollee's treating physician
				or health care provider; and
(d)
				Whether:
(i) The terms of coverage under the
				enrollee's health benefit plan would have covered the treatment had the carrier
				not determined that the treatment was experimental or
				investigational;
(ii) The
				recommended or requested health care service or treatment has been approved by
				the federal Food and Drug Administration, if applicable, for the condition;
				or
(iii) Medical or scientific
				evidence or evidence-based standards demonstrate that the recommended or
				requested health care service or treatment is more likely than any available
				standard health care service or treatment to be beneficial to the enrollee and
				the adverse risks would not be substantially increased over those of available
				standard health care services or treatments.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-100 - Ongoing requirements for IROs

Current through Register Vol. 24-14, July 15, 2024
A certified IRO shall:
(1) Comply with the provisions of
				RCW
				 48.43.535(5), and this
				chapter;
(2) Cooperate with the
				commissioner during investigations;
(3) Provide the commissioner with information
				requested in a prompt manner. A lack of response within fifteen business days
				from receipt of an inquiry will be considered untimely;
(4) Conduct annual self-assessments of
				compliance with Washington certification requirements;
(5) Maintain certification. Independent
				review organizations that are certified as of December 31st of the calendar
				year will be required to submit an annual recertification, using the
				commissioner's online service, no later than March 31st of the following
				calendar year. Recertification requires the following:
(a) Submission of an annual attestation on
				the form required by the commissioner, signed by a company officer, certifying
				that all requirements within
				RCW
				 48.43.537 and this title will be
				met.
(b) Submission of updated
				information to the commissioner if at any time there is a change in the
				information included in the application.
(c) Submit an annual statistical report with
				the commissioner on a form specified by the commissioner summarizing reviews
				conducted. The report shall include, but may not be limited to, volumes, types
				of cases, compliance with timelines for expedited and nonexpedited cases,
				determinations, number and nature of complaints, and compliance with the
				conflict of interest requirements described in WAC 284-43A-050.
(d) Submit any other pertinent information
				required by the commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-110 - Powers of the commissioner

Current through Register Vol. 24-14, July 15, 2024
(1) The
				commissioner may deny, suspend, revoke, or modify certification of an IRO if
				the commissioner has reason to believe the applicant, certified IRO, its
				agents, officers, directors, or any person with any interest in the IRO has
				failed or refused to comply with the requirements established under this
				chapter.
(2) The commissioner may
				conduct an on-site review, audit, and examine records to investigate complaints
				alleging that an applicant, certified IRO, or reviewer committed any conduct
				described in WAC 284-43A-120.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter B - CERTIFICATION AND REQUIREMENTS FOR INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-130 - Maximum fee schedule

Current through Register Vol. 24-14, July 15, 2024
This section sets the maximum fee schedule for independent
				  reviews, and the process of review and determination of a case referred to an
				  independent review organization (IRO).
(1) IROs may not charge more than the
				following amount for each review:
Category
Amount
Contract review, interpretation of health
						  plan coverage provisions
$600
Standard medical review, straightforward
						  review of medical necessity or adverse determination
$700
Highly specialized medical review of
						  complex conditions or experimental or investigational treatment
$1000
Medical review with multiple reviewers
$1100
Surcharge for expedited review
$200
The fees in this section include all costs for time and
				  materials associated with the review including, but not limited to:
(a) Record transmission expenses such as
				postage and facsimile costs; and
(b) Medical record handling and
				duplication.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43A - INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Subchapter C - REQUIREMENTS FOR CARRIERS IN USING INDEPENDENT REVIEW ORGANIZATIONS (IROs) › Section 284-43A-150 - Independent review of adverse determinations

Current through Register Vol. 24-14, July 15, 2024
Carriers must use the rotational registry system of
				  certified independent review organizations (IROs) established by the
				  commissioner.
(1) Using the
				commissioner's online service carriers must select reviewing IROs in the
				rotational manner described in the rotational registry system. A carrier may
				not make an assignment to an IRO out of sequence for any reason other than the
				existence of a conflict of interest, as set forth in WAC 284-43A-050.
(2) The rotational registry system, a current
				list of certified IROs, IRO assignment instructions, and an IRO assignment form
				to be used by carriers are set forth on the insurance commissioner's web site
				(
www.insurance.wa.gov
).
(3) In addition to the requirements set forth
				in RCW
				 48.43.535(4), carriers must:
(a) Make available to the covered person and
				to any provider acting on behalf of the covered person all materials provided
				to an independent review organization reviewing the carrier's determination;
				and
(b) Provide IROs with:
(i) All relevant clinical review criteria
				used by the carrier and other relevant medical, scientific, and
				cost-effectiveness evidence;
(ii)
				The attending or ordering provider's recommendations; and
(iii) A copy of the terms and conditions of
				coverage under the relevant health plan.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-015 - Coverage of emergency services

Current through Register Vol. 24-14, July 15, 2024
(1) Coverage of
			 emergency services is governed by
			 RCW
			  48.43.093. Emergency services, as defined in
			 RCW
			  48.43.005, include services provided after an
			 en-rollee is stabilized and as part of outpatient observation or an inpa-tient
			 or outpatient stay with respect to the visit during which screening and
			 stabilization services have been furnished. Poststabili-zation services relate
			 to medical, mental health or substance use disorder treatment necessary in the
			 short term to avoid placing the health of the individual, or with respect to a
			 pregnant person, the health of a person or their unborn child, in serious
			 jeopardy, serious impairment to bodily functions, or serious dysfunction of any
			 bodily organ or part.
(2) A carrier
			 may require notification of stabilization or inpa-tient admission of an
			 enrollee as provided in
			 RCW
			  48.43.093. Regardless of such notification,
			 payment and cost-sharing for poststabiliza-tion services provided by a
			 nonparticipating facility, provider or behavioral health emergency services
			 provider and dispute resolution related to those services are governed by
			 RCW
			  48.49.040 and
			 48.49.160.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-020 - Balance billing prohibition and consumer cost-sharing

Current through Register Vol. 24-14, July 15, 2024
(1) If an enrollee
			 receives any emergency services from a nonparticipating facility, provider, or
			 be- havioral health emergency services provider, any nonemergency health care
			 services performed by a nonparticipat-ing provider at certain participating
			 facilities, or any air ambulance services from a nonparticipating provider:
(a) The enrollee satisfies their obligation
			 to pay for the health care services if they pay the in-network cost-sharing
			 amount specified in the enrollee's or applicable group's health plan contract.
			 The enrollee's obligation must be calculated as if the total amount charged for
			 the services were equal to:
(i) For emergency
			 services other than services provided by emergency behavioral health services
			 providers, for nonemergency health care services performed by a
			 nonparticipating provider at certain participating facilities, and for air
			 ambulance services, the lesser of the qualifying payment amount, as determined
			 in accordance with  45 C.F.R. Sec. 149.140, or billed charges; and
(ii) For services provided by emergency
			 behavioral health services providers, the qualifying payment amount, as
			 determined in accordance with  45 C.F.R. Sec. 149.140. The carrier must provide
			 an explanation of benefits to the enrollee and the non-participating provider,
			 facility, emergency behavioral health services provider or air ambulance
			 provider that reflects the cost-sharing amount determined under this
			 subsection.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-030 - Out-of-network claim payment and placing a claim into dispute

Current through Register Vol. 24-14, July 15, 2024
For services described in
				RCW
				 48.49.020(1) (other than air
				ambulance services) provided prior to July 1, 2023, or a later date determined
				by the commissioner, and for services provided by a nonparticipating emergency
				behavioral health services provider if the federal government does not
				authorize use of the federal independent dispute resolution system for these
				disputes, the allowed amount paid to a nonparticipating provider or facility
				for emergency services and nonemergency health care services performed by
				non-participating providers at certain participating facilities, shall be a
				commercially reasonable amount, based on payments for the same or similar
				services provided in the same or a similar geographic area.
(1) Within 30 calendar days of receipt of a
			 claim from a nonparticipating provider or facility, the carrier shall offer to
			 pay the provider or facility a commercially reasonable amount. Payment of an
			 adjudicated claim shall be considered an offer to pay. The amount actually paid
			 to a nonparticipating provider by a carrier may be reduced by the applicable
			 consumer cost-sharing determined under WAC
			 284-43B-020(1)(a).
			 The date of receipt by the provider or facility of the carrier's offer to pay
			 is five calendar days after a transmittal of the offer is mailed to the
			 provider or facility, or the date of transmittal of an electronic notice of
			 payment. The claim submitted by the nonparticipating provider or facility to
			 the carrier must include the following information:
(a) Patient name;
(b) Patient date of birth;
(c) Provider name;
(d) Provider location;
(e) Place of service, including the name and
			 address of the facility in which, or on whose behalf, the service that is the
			 subject of the claim was provided;
(f) Provider federal tax identification
			 number;
(g) Federal Center for
			 Medicare and Medicaid Services individual national provider identifier number,
			 and organizational national provider identifier number, if the provider works
			 for an organization or is in a group practice that has an organization
			 number;
(h) Date of service;
(i) Procedure code; and
(j) Diagnosis code.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-032 - Applicable dispute resolution system

Current through Register Vol. 24-14, July 15, 2024
(1) Effective for
			 services provided on or after July 1, 2023, or a later date determined by the
			 commissioner, services described in
			 RCW
			  48.49.020(1) other than air
			 ambulance services are subject to the independent dispute resolution process
			 established in sections 2799A-1 and 2799A-2 of the Public Health Service Act
			 (42 U.S.C. Secs. 300gg-111 and 300gg-112) and federal regulations implementing
			 those sections of P.L.
			 116-260 (enacted December 27, 2020). Until July 1,
			 2023, or a later date determined by the commissioner, the arbitration process
			 in this chapter governs the dispute resolution process for those
			 services.
(2) Effective for
			 services provided on or after July 1, 2023, or a later date determined by the
			 commissioner, if the federal independent dispute resolution process is
			 available to the state, behavioral emergency services provider services
			 described in
			 RCW
			  48.49.020(3) are subject to
			 the independent dispute resolution process established in section 2799A-1 and
			 2799A-2 of the Public Health Service Act (42 U.S.C. Secs. 300gg-111 and 300gg-112) and federal regulations implementing those sections of
			 P.L.
			 116-260 (enacted December 27, 2020). Until July 1,
			 2023, or a later date determined by the commissioner, or if the federal
			 independent dispute resolution process is not available to the state for
			 resolution of these disputes, the arbitration process in this chapter governs
			 the dispute resolution process for those services.
(3) The office of the insurance commissioner
			 must provide a minimum of four months advance notice of the date on which the
			 dispute resolution process will transition to the federal independent dispute
			 resolution process. The notice must be posted on the website of the office of
			 the insurance commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-037 - Arbitration proceedings

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of
			 calculating the date that written submissions to the arbitrator under
			 RCW
			  48.49.040 are due, final selection of the
			 arbitrator occurs on the date that the commissioner sends by electronic
			 transmittal the notice of selection to the arbitrator. The parties must be
			 copied on such notice.
(2) Good
			 cause for purposes of delay in written submissions to the arbitrator under
			 RCW
			  48.49.040 includes a stipulation that the
			 parties intend to complete settlement negotiations prior to making such
			 submissions to the arbitrator.
(3)
			 If the parties agree on an out-of-network rate for the services at issue after
			 submitting an arbitration initiation request but before the arbitrator has made
			 a decision, they must provide notice to the commissioner as provided in
			 RCW
			  48.49.040(7).
(4) If an initiating party withdraws an
			 arbitration initiation request at any point before the arbitrator has made a
			 decision, the party must submit to the commissioner notice of the date of the
			 withdrawal of the request, as soon as possible, but no later than three
			 business days after the date of the withdrawal.
(5) Any enrollee or patient information
			 submitted to the arbitrator in support of the final offer shall be
			 de-identified to ensure that protected health information is not
			 disclosed.
(6) The decision of the
			 arbitrator is final and binding on the parties and is not subject to judicial
			 review. The arbitrator must submit to the commissioner:
(a) Their decision, including an explanation
			 of the elements of the parties' submissions the arbitrator relied upon to make
			 their decision and why those elements were relevant to their decision;
			 and
(b) The information required in
			 RCW
			  48.49.050 using the form found in Appendix B
			 to this rule, or for arbitration proceedings under
			 RCW
			  48.49.135, using the form found in Appendix C
			 to this rule.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-040 - Determining whether an enrollee's health plan is subject to the requirements of the act

Current through Register Vol. 24-14, July 15, 2024
(1) To implement
			 RCW
			  48.49.170 carriers must make information
			 regarding whether an enrollee's health plan is subject to the requirements of
			 chapter 48.49 RCW or section 2799A-1 et seq. of the Public Health Service Act
			 (42 U.S.C. Sec. 300gg-111  et seq.) and federal regulations implementing those
			 provisions of P.L.
			 116-260 available to providers and facilities by:
(a) Using the most current version of the
			 Health Insurance Portability and Accountability Act (HIPAA) mandated X12 Health
			 Care Eligibility Benefit Response (271) transaction information through use of
			 the most appropriate standard message that is placed in a standard location
			 within the 271 transaction;
(b)
			 Beginning April 1, 2021, and until December 31, 2022, using the most current
			 version of the Health Insurance Portability and Accountability Act (HIPAA)
			 mandated X12 Health Care Claim Payment and Remittance Advice (835) transaction
			 through compliant use of the X12 industry standard Remark Code N830 to indicate
			 that the claim was processed in accordance with this state's balance billing
			 rules;
(c) Beginning January 1,
			 2023, using the appropriate version of the Health Insurance Portability and
			 Accountability Act (HIPAA) mandated X12 Health Care Claim Payment and
			 Remittance Advice (835) transaction through compliant use of the applicable X12
			 industry standard Remark Code to indicate whether a claim was processed in
			 accordance with this state's balance billing rules or the federal No Surprises
			 Act.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-050 - Notice of consumer rights and transparency

Current through Register Vol. 24-14, July 15, 2024
(1) The
			 commissioner shall develop a standard template for a notice of consumer
			 protections from balance billing under the Balance Billing Protection Act and
			 the federal No Surprises Act (P.L. 116-260). The notice may
			 be modified periodically, as determined necessary by the commissioner. The
			 notice template will be posted on the public website of the office of the
			 insurance commissioner.
(2) The
			 standard template for the notice of consumer protections developed under
			 subsection (1) of this section must be provided to consumers enrolled in any
			 health plan issued in Washington state as follows:
(a) Carriers must:
(i) Include the notice in the carrier's
			 communication to an enrollee, in electronic or any other format, that
			 authorizes nonemergency services to be provided at facilities referenced in WAC
			 284-43B-010(2)(h)(ii);
(ii) Include the notice in each explanation
			 of benefits sent to an enrollee for items or services with respect to which the
			 requirements of
			 RCW
			  48.49.020 and WAC
			 284-43B-020 apply;
(iii) Post the notice on their website in a
			 prominent and relevant location, such as in a location that addresses coverage
			 of emergency services and prior authorization requirements for nonemergency
			 health care services performed by nonparticipating providers at certain
			 participating facilities; and
(iv)
			 Provide the notice to any enrollee upon request.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-060 - Enforcement

Current through Register Vol. 24-14, July 15, 2024
(1)
(a) If the commissioner has cause to believe
			 that any health facility, behavioral health emergency services provider or
			 provider has engaged in a pattern of unresolved violations of
			 RCW
			  48.49.020 or
			 48.49.030, the commissioner may
			 submit information to the department of health or the appropriate disciplining
			 authority for action.
(b) In
			 determining whether there is cause to believe that a health care provider,
			 behavioral health emergency services provider or facility has engaged in a
			 pattern of unresolved violations, the commissioner shall consider, but is not
			 limited to, consideration of the following:
(i) Whether there is cause to believe that
			 the health care provider, behavioral health emergency services provider or
			 facility has committed two or more violations of
			 RCW
			  48.49.020 or
			 48.49.030;
(ii) Whether the health care provider,
			 behavioral health emergency services provider or facility has failed to submit
			 claims to carriers containing all of the elements required in WAC
			 284-43B-030(1)
			 on multiple occasions, putting a consumer or consumers at risk of being billed
			 for services to which the prohibition in
			 RCW
			  48.49.020 applies;
(iii) Whether the health care provider,
			 behavioral health emergency services provider or facility has been
			 nonresponsive to questions or requests for information from the commissioner
			 related to one or more complaints alleging a violation of
			 RCW
			  48.49.020 or
			 48.49.030; and
(iv) Whether, subsequent to correction of
			 previous violations, additional violations have occurred.
(c) Prior to submitting information to the
			 department of health or the appropriate disciplining authority, the
			 commissioner may provide the health care provider, behavioral health emergency
			 services provider or facility with an opportunity to cure the alleged
			 violations or explain why the actions in question did not violate
			 RCW
			  48.49.020 or
			 48.49.030.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-070 - Self-funded group health plan opt in

Current through Register Vol. 24-14, July 15, 2024
(1) A self-funded
			 group health plan that elects to participate in
			 RCW
			  48.49.020 through
			 48.49.040 and
			 48.49.160, shall provide notice to
			 the commissioner of their election decision on a form prescribed by the
			 commissioner. The completed form must include an attestation that the
			 self-funded group health plan has elected to participate in and be bound by
			 RCW
			  48.49.020 through
			 48.49.040,
			 48.49.160 and rules adopted to
			 implement those sections of law. If the form is completed by the self-funded
			 group health plan, the plan must inform any entity that administers the plan of
			 their election to participate. The form will be posted on the commissioner's
			 public website for use by self-funded group health plans.
(2) A self-funded group health plan election
			 to participate is for a full year. The plan may elect to initiate its
			 participation on January 1st of any year or in any year on the first day of the
			 self-funded group health plan's plan year.
(3) A self-funded group health plan's
			 election occurs on an annual basis. On its election form, the plan must
			 indicate whether it chooses to affirmatively renew its election on an annual
			 basis or whether it should be presumed to have renewed on an annual basis until
			 the commissioner receives advance notice from the plan that it is terminating
			 its election as of either December 31st of a calendar year or the last day of
			 its plan year. Notices under this subsection must be submitted to the
			 commissioner at least 15 days in advance of the effective date of the election
			 to initiate participation and the effective date of the termination of
			 participation.
(4) A self-funded
			 plan operated by an out-of-state employer that has at least one employee who
			 resides in Washington state may elect to participate in balance billing
			 protections as provided in
			 RCW
			  48.49.130 on behalf of their Washington state
			 resident employees and dependents. If a self-funded group health plan
			 established by Washington state employer has elected to participate in balance
			 billing protections under
			 RCW
			  48.49.130 and has employees that reside in
			 other states, those employees are protected from balance billing when receiving
			 care from a Washington state provider.
(5) Self-funded group health plan sponsors
			 and their third party administrators may develop their own internal processes
			 related to member notification, member appeals and other functions associated
			 with their fiduciary duty to enrollees under the Employee Retirement Income
			 Security Act of 1974 (ERISA).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-075 - Severability

Current through Register Vol. 24-14, July 15, 2024
If any provision of this chapter or its application to any
				person or circumstance is for any reason held to be invalid by a court, the
				remainder of this chapter and the application of the provisions to other
				persons or circumstances shall not be affected.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-010 - Title and application

Current through Register Vol. 24-14, July 15, 2024
(1) This
			 regulation, WAC
			 284-44-010 through
			 284-44-070, is promulgated
			 pursuant to
			 RCW
			  48.44.050 and
			 48.44.020, and may be cited as the
			 "Washington state health care service contractor regulation."
(2) This regulation, chapter 284-44 WAC,
			 shall apply to every health care service contractor (hereinafter referred to as
			 "contractor") registered pursuant to
			 RCW
			  48.44.015.
Order R-74-1, §
										284-44-010, filed 6/4/74,
				  effective 8/1/74.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-015 - Discretionary clauses prohibited

Current through Register Vol. 24-14, July 15, 2024
(1) No contract may contain a discretionary
			 clause. "Discretionary clause" means a provision that purports to reserve
			 discretion to a carrier, its agents, officers, employees, or designees in
			 interpreting the terms of a contract or deciding eligibility for benefits, or
			 requires deference to such interpretations or decisions, including a provision
			 that provides for any of the following results:
(a) That the carrier's interpretation of the
			 terms of the contract is binding;
(b) That the carrier's decision regarding
			 eligibility or continued receipt of benefits is binding;
(c) That the carrier's decision to deny,
			 modify, reduce or terminate payment, coverage, authorization, or provision of
			 health care service or benefits, is binding;
(d) That there is no appeal or judicial
			 remedy from a denial of a claim;
(e) That deference must be given to the
			 carrier's interpretation of the contract or claim decision; and
(f) That the standard of review of a
			 carrier's interpretation of the contract or claim decision is other than a de
			 novo review.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-030 - Contract format required

Current through Register Vol. 24-14, July 15, 2024
Every health care service contract issued or renewed after
				December 31, 1974 shall conform to the following format standards:
(1) The style, arrangement and over-all
			 appearance of the contract shall give no undue prominence to any portion of the
			 text, and every printed portion of the text of the contract and of any
			 endorsements or attached papers shall be plainly printed in type of a style in
			 general use, the size of which shall be uniform and not less than eight-point
			 with a lower-case unspaced alphabet length not less than one hundred and
			 twenty-point. The "text" shall include all printed matter except the name and
			 address of the contractor, name or title of the policy, a brief description if
			 any, and captions and subcaptions.
(2) The exceptions, reductions, and
			 limitations (as those terms are defined in WAC
			 284-50-030)  shall be set forth
			 in the contract either included with the benefit provisions to which they
			 apply, or under an appropriate caption such as "exclusions," "exceptions," or
			 "exceptions and limitations," except that if an exception, reduction, or
			 limitation specifically applies only to a particular benefit under the
			 contract, a statement of such exception, reduction, or limitation shall be
			 included with the benefit provision to which it applies.
(3) Each form, including riders and
			 endorsements, shall be identified by a form number in the lower left hand
			 corner of the first page thereof.
(4) It shall contain no provision purporting
			 to make any portion of the contractor's charter, rules, constitution, articles
			 of incorporation, or bylaws a part of the contract if the effect of such
			 provision would be to incorporate into the contract exceptions, reductions,
			 limitations or additional charges not otherwise set forth in the contract,
			 unless such portion is set forth in full in the contract, or is attached
			 thereto.
Order R-74-1, §
										284-44-030, filed 6/4/74,
				  effective 8/1/74.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-042 - Temporomandibular joint disorders - Specified offer of coverage required - Terms of specified offer defined - Proof of offer must be maintained - Discrimination prohibited - Terms defined

Current through Register Vol. 24-14, July 15, 2024
(1)
			 Pursuant to
			 RCW
			  48.44.460, each offer of new or renewal group
			 coverage made on or after January 1, 1993, must include one or more offers of
			 optional coverage for the treatment of temporomandibular joint disorders.
			 Health care service contractors are encouraged to exercise broad flexibility in
			 designing benefits for these optional temporomandibular joint disorder coverage
			 offerings. However, compliance with the statute shall be demonstrated only when
			 one of the optional temporomandibular joint disorder coverage offerings
			 provides benefits as follows:
(a) Offers
			 limited to only medical coverage shall provide coverage for medical services
			 related to the treatment of temporomandibular joint disorders in the amount of
			 one thousand dollars per covered individual, after the application of
			 deductibles, coinsurance, and copayments, in any calendar year, and a lifetime
			 benefit of five thousand dollars per covered individual, after the application
			 of deductibles, coinsurance, and copayments. Other than the benefit amount,
			 coverage for medical services shall be the same as are generally provided in
			 the health care service contract for other injuries or musculoskeletal
			 disorders. The coverage provisions may require:
(i) That services either be rendered or
			 referred by the covered individual's primary care physician; and
(ii) A second opinion, provided that the
			 covered individual shall not be financially responsible for any costs relating
			 to this second opinion and that such costs shall be in excess of the required
			 benefit levels; and
(iii)
			 Prenotification or preauthorization.
Except
that the coverage provisions shall not require either
							 a second opinion or prenotification or preauthorization for treatment
							 commencing within forty-eight hours, or as soon as is reasonably possible,
							 after the occurrence of an accident or trauma to the temporomandibular
							 joint.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-043 - Experimental and investigational prescriptions, treatments, procedures, or services - Definition required - Standard for definition - Written notice of denial required - Appeal process required

Current through Register Vol. 24-14, July 15, 2024
(1) Every health care service contract which
			 excludes or limits, or reserves the right to exclude or limit, benefits for any
			 treatment, procedure, facility, equipment, drug, drug usage, medical device, or
			 supply (hereinafter individually and collectively referred to as services) for
			 one or more medical condition or illness because such services are deemed to be
			 experimental or investigational must include within the contract and any
			 certificate of coverage issued thereunder, a definition of experimental or
			 investigational.
(2) The definition
			 of experimental or investigational services must include an identification of
			 the authority or authorities which will make a determination of which services
			 will be considered to be experimental or investiga-tional. If the health care
			 service contractor specifies that it, or an affiliated entity, is the authority
			 making the determination, the criteria it will utilize to determine whether a
			 service is experimental or investigational must be set forth in the contract
			 and any certificate of coverage issued thereunder. As an example, and not by
			 way of limitation, the requirement to set forth criteria in the contract and
			 any certificate of coverage issued thereunder may be satisfied by using one or
			 more of the following statements, or other similar statements:
(a) "In determining whether services are
			 experimental or investigational, the plan will consider whether the services
			 are in general use in the medical community in the state of Washington, whether
			 the services are under continued scientific testing and research, whether the
			 services show a demonstrable benefit for a particular illness or disease, and
			 whether they are proven to be safe and efficacious."
(b) "In determining whether services are
			 experimental or investigational, the plan will consider whether the services
			 result in greater benefits for a particular illness or disease than other
			 generally available services, and do not pose a significant risk to health or
			 safety of the patient."
The supporting documentation upon which the criteria are
				established must be made available for inspection upon written request in all
				instances and may not be withheld as proprietary.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-046 - Mammograms-Coverage requirements and exceptions

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
			 this regulation is to effectuate the provisions of
			 RCW
			  48.44.325 by establishing definitions for the
			 exceptions to coverage for mammograms. This regulation shall apply to every
			 group and individual health care service contract which is delivered or issued
			 for delivery or renewed in this state on or after September 1, 1992, that
			 provides for hospital or medical care.
(2) For the purposes of
			 RCW
			  48.44.325 and this regulation, supplemental
			 contracts covering specified disease shall be defined to mean and include only
			 those contracts which provide benefits to a member only in the event that the
			 member contracts the disease or diseases specifically named in the contract.
			 Also for the purposes of
			 RCW
			  48.44.325 and this regulation, supplemental
			 contracts covering limited benefits shall be defined to mean and include only
			 those contracts providing only one of the following benefits: Hospital
			 indemnity, accident only coverage, dental care, vision care, mental health
			 care, chemical dependency care, pharmaceutical care, and podiatric
			 care.
(3) Coverage of mammograms
			 may be subject to standard contract provisions, except the cost-sharing
			 provisions prohibited by
			 RCW
			  48.43.076, which may be applicable to other
			 diagnostic X-ray benefits.
(4) For
			 purposes of this section:
(a) "Diagnostic
			 breast examination" means a medically necessary and appropriate examination of
			 the breast, as defined in
			 RCW
			  48.43.076. Diagnostic breast examinations are
			 used to evaluate an abnormality either seen or suspected from a breast cancer
			 screening examination, or detected by another means of examination.
(b) "Supplemental breast examination" has the
			 meaning set forth in
			 RCW
			  48.43.076.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-050 - Group certificates to be furnished

Current through Register Vol. 24-14, July 15, 2024
Every contractor shall issue to the employer, a contract
				holder, or other person or association in whose name a contract is issued, for
				delivery to each person covered by a group contract, a certificate setting
				forth in summary form a statement of the essential features of the contract
				coverage, and to or for whom the benefits thereunder are payable. If family
				members are covered, only one certificate need be issued for each family. In
				the event that contracts are changed or amended, new certificates or a clearly
				understandable amendment to existing certificates shall be promptly furnished.
				The style, arrangement, and over-all appearance of the certificate shall not be
				less favorable than the requirements imposed by WAC
				284-44-030. Such "certificate"
				may be in the form of a comprehensive booklet or brochure. The form of such
				certificate shall be filed with the insurance commissioner.
Order R-74-1, §
										284-44-050, filed 6/4/74,
				  effective 8/1/74.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-070 - Effective date

Current through Register Vol. 24-14, July 15, 2024
The effective date of this regulation shall be August 1,
				1974.
Order R-74-1, §
										284-44-070, filed 6/4/74,
				  effective 8/1/74.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-44 - Health care services contractors-Agents-Contract formats-Standards › Section 284-44-250 - Accounting method

Current through Register Vol. 24-14, July 15, 2024
Beginning January 1, 1983, to aid in the administration of
				chapter
				48.44 RCW, every health
				care service contractor shall account for its business on the accrual basis,
				and any annual financial statement filed after December 31, 1983, pursuant to
				RCW
				 48.44.095, shall be reported on such accrual
				basis.
Statutory Authority:
				  RCW
				  48.44.050. 82-23-010 (Order R 82-6), §
										284-44-250, filed 11/5/82,
				  effective 1/1/83.