Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter F - GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES › Section 284-43-4040 - Procedures for review and appeal of adverse determinations

Current through Register Vol. 24-14, July 15, 2024
(1) An enrollee or
				the enrollee's representative, including the treating provider (regardless of
				whether the provider is affiliated with the carrier) acting on behalf of the
				enrollee may appeal an adverse determination in writing. The carrier must
				reconsider the adverse determination and notify the enrollee of its decision
				within fourteen days of receipt of the appeal unless the carrier notifies the
				enrollee that an extension is necessary to complete the appeal; however, the
				extension cannot delay the decision beyond thirty days of the request for
				appeal, without the informed, written consent of the enrollee.
Whenever an adverse determination relates to a protected
				  individual, as defined in
				  RCW
				   48.43.005, the health carrier must follow
				  RCW
				   48.43.505.
(2) Whenever a health carrier makes an
				adverse determination and delay would jeopardize the enrollee's life or
				materially jeopardize the enrollee's health, the carrier shall expedite and
				process either a written or an oral appeal and issue a decision no later than
				seventy-two hours after receipt of the appeal. If the treating health care
				provider determines that delay could jeopardize the enrollee's health or
				ability to regain maximum function, the carrier shall presume the need for
				expeditious review, including the need for an expeditious determination in any
				independent review under WAC 284-43-4040 and
				284-43A-150.
(3) A carrier may not take or threaten to
				take any punitive action against a provider acting on behalf or in support of
				an enrollee appealing an adverse determination.
(4) Appeals of adverse determinations shall
				be evaluated by health care providers who were not involved in the initial
				decision and who have appropriate expertise in the field of medicine that
				encompasses the enrollee's condition or disease.
(5) All appeals must include a review of all
				relevant information submitted by the enrollee or a provider acting on behalf
				of the enrollee.
(6) The carrier
				shall issue to affected parties and to any provider acting on behalf of the
				enrollee a written notification of the adverse determination that includes the
				actual reasons for the determination, the instructions for obtaining an appeal
				of the carrier's decision, a written statement of the clinical rationale for
				the decision, and instructions for obtaining the clinical review criteria used
				to make the determination.
Whenever an adverse determination notification relates to a
				  protected individual, as defined in
				  RCW
				   48.43.005, the health carrier must follow
				  RCW
				   48.43.505.
Statutory Authority: RCW  48.02.060, 48.43.525, 48.43.530,
					 48.43.535, and The Patient Protection and Affordable Care Act,  P.L. 111-148, as
					 amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-620, filed
					 11/7/12, effective 11/20/12. Statutory Authority: RCW  48.02.060, 48.18.120,
					 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505,
					 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535. WSR 01-03-033
					 (Matter No. R 2000-02), § 284-43-620, filed 1/9/01, effective 7/1/01.
					 Statutory Authority: RCW  48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010,
					 48.43.055, 48.44.050, 48.46.100 and 48.46.200. WSR 99-24-075 (Matter No. R
					 98-17), § 284-43-620, filed 11/29/99, effective
					 12/30/99.