reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-350 - Issuer standards for women's right to directly access certain health care practitioners for women's health care services

Current through Register Vol. 24-14, July 15, 2024
(1)
(a) "Women's health care services" means
				organized services to provide health care to women, inclusive of the women's
				preventive services required by the Health Resources and Services
				Administration of the U.S. Department of Health and Human Services. The
				services include, but are not limited to, maternity care, reproductive health
				services, gynecological care, general examination, and preventive care as
				medically appropriate, and medically appropriate follow-up visits for these
				services. Women's health care services also include any appropriate health care
				service for other health problems, discovered and treated during the course of
				a visit to a women's health care practitioner for a women's health care
				service, which is within the practitioner's scope of practice. For purposes of
				determining a woman's right to directly access health services covered by the
				plan, maternity care, reproductive health, and preventive services include:
				Contraceptive services, testing and treatment for sexually transmitted
				diseases, pregnancy termination, breast-feeding, and complications of
				pregnancy.
(b) An issuer must not
				exclude or limit access to covered women's health care services offered by a
				particular type of women's health care provider, practitioner, or facility in a
				manner that would unreasonably restrict access to that type of provider,
				practitioner, or facility or covered service. For example, an issuer must not
				impose a limitation on maternity services that would require all child birth to
				occur in a hospital attended by a physician, thus preventing a woman from
				choosing between and using the birthing services of an advanced registered
				nurse practitioner, a certified midwife, or a licensed midwife.
(c) An issuer must not impose notification or
				prior authorization requirements upon women's health care practitioners,
				providers, and facilities who render women's health care services or upon women
				who directly access such services unless such requirements are imposed upon
				other providers offering similar types of service. For example, an issuer must
				not require a directly accessed women's health care practitioner to notify the
				plan within seven days of providing direct women's health care services if a
				primary care provider would not also be required to provide seven-day notice to
				the issuer for the same or similar service.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-360 - Enrollee's access to providers

Current through Register Vol. 24-14, July 15, 2024
(1) Each issuer must allow an enrollee to
				choose a primary care provider who is accepting new patients from a list of
				participating providers.
(a) Enrollees also
				must be permitted to change primary care providers at any time with the change
				becoming effective not later than the beginning of the month following the
				enrollee's request for the change.
(b) The issuer must ensure at all times that
				there are a sufficient number of primary care providers in the service area
				accepting new patients to accommodate new enrollees if the plan is open to new
				enrollment, and to ensure that existing enrollees have the ability to change
				primary care providers.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-370 - Hospital emergency service departments and practice groups

Current through Register Vol. 24-14, July 15, 2024
Enrollees must have access to emergency services twenty-four
				  hours per day, seven days per week. An issuer must make good faith attempts to
				  contract with provider groups offering services within hospital emergency
				  departments, if the hospital is included in its network. Such evidence of good
				  faith efforts to contract will include documentation about the efforts to
				  contract but not the substantive contract terms offered by either the issuer or
				  the provider groups. If the issuer is unsuccessful in contracting with provider
				  groups offering services within contracted hospital emergency departments, the
				  issuer's provider directory must prominently note that while the hospital's
				  emergency department is contracted, the providers within the department are
				  not.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-380 - Standards for temporary substitution of contracted network providers-"Locum tenens" providers

Current through Register Vol. 24-14, July 15, 2024
It is a longstanding and widespread practice for contracted
				  network providers to retain substitute providers to take over their
				  professional practices when the contracted network providers are absent for
				  reasons such as illness, pregnancy, vacation, or continuing medical education,
				  and for contracted network providers to bill and receive payment for the
				  substitute providers' services as though they were provided by the contracted
				  network provider. The contracted network provider generally pays the substitute
				  provider based on an agreement between the contracted network provider and the
				  substitute provider, and the substitute provider has the status of an
				  independent contractor rather than an employee of the contracted network
				  provider. These substitute providers are commonly called "locum tenens"
				  providers.
In order to protect patients and ensure that they benefit
				  from seamless quality care when contractual network providers are away from
				  their practices, and that patients receive quality care from qualified
				  substitute providers, carriers may require substitute providers to provide the
				  information required in subsection (1) of this section.
The following are minimum standards for temporary provider
				  substitution and do not prevent a carrier from entering into other agreed
				  arrangements with its contracted network providers for terms that are less
				  restrictive or more favorable to providers.
Carriers must permit the following categories of contracted
				  network provider to arrange for temporary substitution by a substitute
				  provider: Doctor of medicine, doctor of osteopathic medicine, doctor of dental
				  surgery or dental medicine, doctor of chiropractic, podiatric physician and
				  surgeon, doctor of optometry, doctor of naturopathic medicine and advanced
				  registered nurse practitioner.
(1) At
				the time of substitution, the substitute provider:
(a) Must have a current Washington license
				and be legally authorized to practice in this state;
(b) Must provide services under the same
				scope of practice as the contracted network provider;
(c) Must not be suspended or excluded from
				any state or federal health care program;
(d) Must have professional liability
				insurance coverage; and
(e) Must
				have a current drug enforcement certificate, if applicable.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter B - HEALTH CARE NETWORKS › Section 284-170-390 - Rule concerning contracted network providers called to active duty military service

Current through Register Vol. 24-14, July 15, 2024
In lieu of substitution of a provider during a period of
				  active duty military service longer than sixty continuous days, carriers must
				  provide contracted network providers with the opportunity to return to the
				  carrier's network after the provider's active duty military service is
				  completed.
(1)
(a) A carrier must allow the provider a
				period of at least one hundred twenty days to request a return to contracted
				network provider status after the provider returns to civilian
				status.
(b) The one hundred
				twenty-day period must begin no earlier than the date the provider's period of
				active duty ends.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-400 - Preexisting condition limitations (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-400, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-401 - Provider and facility contracts with issuers-Generally

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer contracting with providers or
				facilities for health care service delivery to enrollees must satisfy all the
				requirements contained in this subchapter.
(2) An issuer must ensure that subcontractors
				of its contracted providers and facilities comply with the requirements of this
				subchapter. An issuer's obligation to comply with these requirements is
				nondelegable; the issuer is not exempt from these requirements because it
				relied upon a third-party vendor or subcontracting arrangement.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-410 - Special enrollment requirements for small group plans (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-410, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-411 - Selection of participating providers-Credentialing and unfair discrimination

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must
				develop standards for selecting participating providers, for primary care
				providers, and for each health care provider or facility license and
				professional specialty. The standards must be used in determining the selection
				of health care providers and facilities by the issuer. The standards must be
				consistent with rules or standards established by the state department of
				health or other regulatory authority established in
				Title
				18 RCW for health care
				providers specified in
				RCW
				 18.130.040. Selection criteria must not be
				established in a manner that would:
(a) Allow
				an issuer to avoid risk by excluding providers or facilities because they are
				located in geographic areas that contain populations presenting a risk of
				higher than average claims, losses, or health services utilization;
(b) Exclude providers or facilities because
				they treat or specialize in treating persons presenting a risk of higher than
				average claims, losses, or health services utilization or because they treat or
				specialize in treating minority or special populations; or
(c) Discriminate regarding participation in
				the network solely based on the provider or facility type or category if the
				provider is acting within the scope of their license.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-412 - Special enrollment periods for small group qualified health plans (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-412, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-415 - Duration and effective dates of small group special enrollment periods (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-415, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-420 - Individual market open enrollment requirements (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.44.050, 48.46.200 and 45 C.F.R. Parts 144, 146 and 147. WSR 14-08-036
					 (Matter No. R 2014-01), § 284-170-420, filed 3/26/14, effective 4/26/14.
					 Statutory Authority: RCW  48.02.060, 48.18.120(2), 48.20.450, 48.43.0211,
					 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No. R 2013-02), § 284-170-420,
					 filed 12/11/13, effective 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-425 - Individual market special enrollment requirements (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-425, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-430 - Individual market special enrollment period requirements for qualified health plans (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-430, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-431 - Provider contracts-Terms and conditions of payment

Current through Register Vol. 24-14, July 15, 2024
(1) Every participating provider and facility
				contract shall set forth a schedule for the prompt payment of amounts owed by
				the carrier to the provider or facility and shall include penalties for carrier
				failure to abide by that schedule. At a minimum, these contract provisions
				shall conform to the standards of this section.
(2)
(a) For
				health services provided to covered persons, a carrier shall pay providers and
				facilities as soon as practical but subject to the following minimum standards:
(i) Ninety-five percent of the monthly volume
				of clean claims shall be paid within thirty days of receipt by the responsible
				carrier or agent of the carrier; and
(ii) Ninety-five percent of the monthly
				volume of all claims shall be paid or denied within sixty days of receipt by
				the responsible carrier or agent of the carrier, except as agreed to in writing
				by the parties on a claim-by-claim basis.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-433 - Provider contracts-Telemedicine

Current through Register Vol. 24-14, July 15, 2024
(1)
(a)
				Every participating provider contract must, for health plans issued or renewed
				on or after January 1, 2017, provide that a health carrier shall reimburse a
				provider for a health care service provided to a covered person through
				telemedicine or store and forward technology if:
(i) The plan provides coverage of the health
				care service when provided in person by the provider;
(ii) The health care service is medically
				necessary;
(iii) The health care
				service is a service recognized as an essential health benefit under section
				1302(b) of the federal Patient Protection and Affordable Care Act in effect on
				January 1, 2015,
				RCW
				 48.43.005 and
				48.43.715;
(iv) The health care service is determined to
				be safely and effectively provided through telemedicine or store and forward
				technology according to generally accepted health care practices and standards,
				and the technology used to provide the health care service meets the standards
				required by state and federal laws governing the privacy and security of
				protected health information; and
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-435 - Duration, notice requirements and effective dates of coverage for individual market special enrollment periods (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.120(2),
					 48.20.450, 48.43.0211, 48.43.720(3), 48.44.050, 48.46.200,  45 C.F.R. §§
												147.104, 147.106, 155.420, and 155.725. WSR 14-01-042 (Matter No.
					 R 2013-02), § 284-170-435, filed 12/11/13, effective
					 1/1/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-440 - Provider contracts-Dispute resolution process

Current through Register Vol. 24-14, July 15, 2024
Except as otherwise required by a specific federal or state
				  statute or regulation governing dispute resolution, no process for the
				  resolution of disputes arising out of a participating provider or facility
				  contract shall be considered fair under
				  RCW
				   48.43.055 unless the process meets all the
				  provisions of this section.
(1) A
				dispute resolution process may include an initial informal process but must
				include a formal process for resolution of all contract disputes.
(2) A carrier may have different types of
				dispute resolution processes as necessary for specialized concerns such as
				provider credentialing or as otherwise required by law. For example, disputes
				over health plan coverage of health care services are subject to the grievance
				procedures established for covered persons.
(3) Carriers must allow not less than thirty
				days after the action giving rise to a dispute for providers and facilities to
				complain and initiate the dispute resolution process.
(4) Carriers may not require alternative
				dispute resolution to the exclusion of judicial remedies; however, carriers may
				require alternative dispute resolution prior to judicial remedies.
(5) Carriers must render a decision on
				provider or facility complaints within a reasonable time for the type of
				dispute. In the case of billing disputes, the carrier must render a decision
				within sixty days of the complaint.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-450 - Pharmacy identification cards

Current through Register Vol. 24-14, July 15, 2024
(1) This rule outlines the minimum standards
				for prescription claims processing as directed by
				RCW
				 48.43.023.
(2) The pharmacy identification card or other
				technology must include the data element consistent with the "BIN number,"
				"IIN/BIN number" or "RxBIN" which is the ANSI assigned international
				identification number, identified in the
National Council for
				Prescription Drug Programs (NCPDP) Pharmacy ID Card Implementation
				Guide.
Other data elements of the
NCPDP Guide
must be
				included on the card only if they are required for the processing of
				claims.
(3) This rule does not
				compel the issuance of a separate pharmacy identification card provided that
				the enrollee health plan identification card contains the required data
				elements.
(4) All plans that use a
				card or other technology for prescription claims processing that are delivered,
				issued for delivery or renewed on or after July 1, 2003, must comply with the
				requirements of this rule.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-460 - Provider contracts-Audit guidelines

Current through Register Vol. 24-14, July 15, 2024
(1) Provider and facility contracts may not
				contain provisions that grant the carrier access to health information and
				other similar records unrelated to covered persons. This provision shall not
				limit the carrier's right to ask for and receive information relating to the
				ability of the provider or facility to deliver health care services that meet
				the accepted standards of medical care prevalent in the community.
(2) Provider and facility contract provisions
				granting the carrier access to medical records for audit purposes must be
				limited to only that necessary to perform the audit.
(3) Provider and facility contracts may not
				contain billing audit standards that are not mutual. For example, if the
				carrier grants itself the right to audit hospital billing records, then the
				hospital has the right to audit carrier denials of the hospital's
				claims.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-470 - Pharmacy claims-Rejections, notifications and disclosures

Current through Register Vol. 24-14, July 15, 2024
Issuers must provide to billing pharmacies sufficient
				  information about transactions initiated by the pharmacy so that pharmacy
				  claims can be processed in a timely manner.
(1) For purposes of this section "claim
				rejection" is an administrative step in the claim process where a claim is
				neither paid nor denied, but is held awaiting a defined action from the
				pharmacist, prescriber, or member.
(2) An issuer must notify the billing
				pharmacy of a claim rejection electronically and make available to the
				pharmacy, utilizing the National Council for Prescription Drug Programs (NCPDP)
				Telecommunications Standard transaction, all required data elements, as well as
				the following information, to the extent supported by the transaction:
(a) Rejection reasons such as prior
				authorization, quantity level limit, and exclusion;
(b) Other medications to consider that would
				not require a preauthorization (if applicable);
(c) Other medications to consider that would
				require a preauthorization (if applicable);
(d) Instructions for further processing of
				claim or for more specific contact information which may include a reference to
				a specific location on a web site;
(e) Contact phone number of a person or
				department to contact who can provide additional information.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-480 - Participating provider-Filing and approval

Current through Register Vol. 24-14, July 15, 2024
(1) An issuer must file for prior approval
				all participating provider agreements and facility agreements thirty calendar
				days prior to use. If a carrier negotiates a provider or facility contract or a
				compensation agreement that deviates from an approved agreement, then the
				issuer must file that negotiated contract or agreement with the commissioner
				for approval thirty days before use. The commissioner must receive the filings
				electronically in accordance with chapters 284-44A, 284-46A, and 284-58
				WAC.
(2)
(a) An issuer may file a provider or facility
				contract template with the commissioner. A "contract template" is a sample
				contract and compensation agreement form that the issuer will use to contract
				with multiple providers or facilities. A contract template must be issued
				exactly as approved.
(i) When an issuer
				modifies the contract template, an issuer must refile the modified contract
				template for approval. All changes to the contract template must be indicated
				through strike outs for deletions and underlines for new material. The modified
				template must be issued to providers and facilities upon approval.
(ii) Alternatively, issuers may file the
				modified contract template for prospective contracting and a contract addendum
				or amendment that would be issued to currently contracted providers or
				facilities for prior approval. The filing must include any correspondence that
				will be sent to a provider or facility that explains the amendment or addendum.
				The correspondence must provide sufficient information to clearly inform the
				provider or facility what the changes to the contract will be. All changes to
				the contract template must be indicated through strike outs for deletions and
				underlines for new material.
(iii)
				Changes to a previously filed and approved provider compensation agreement
				modifying the compensation amount or terms related to compensation must be
				filed and are deemed approved upon filing if there are no other changes to the
				previously approved provider contract or compensation agreement.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-490 - Effective date

Current through Register Vol. 24-14, July 15, 2024
(1) All
				participating provider and facility contracts entered into after the effective
				date of these rules must comply with these rules no later than January 1,
				2015.
(2) Participating provider
				and facility contracts entered into prior to the effective date of these rules
				must be amended upon renewal to comply with these rules, and all such contracts
				must conform to these provisions no later than January 1, 2015. The
				commissioner may extend the January 1, 2015, deadline for an issuer for an
				additional one year, if the issuer makes a written request. That request must
				explain how a good faith effort at compliance has been made, provide the
				specific reasons the deadline cannot be met, and state the date the issuer
				expects to be in compliance (no more than one year beyond January 1,
				2015).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-800 - Purpose and scope-Pediatric dental benefits for health benefit plans sold outside of the health benefit exchange (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.715. WSR
					 14-09-080 (Matter No. R 2013-19), § 284-170-800, filed 4/18/14, effective
					 5/19/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-805 - Definitions (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.715. WSR
					 14-09-080 (Matter No. R 2013-19), § 284-170-805, filed 4/18/14, effective
					 5/19/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-810 - Pediatric dental benefits design-Methods of satisfying requirements (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060 and 48.43.715. WSR
					 14-09-080 (Matter No. R 2013-19), § 284-170-810, filed 4/18/14, effective
					 5/19/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-870 - Deadline for filing individual health plans, small group health plans, and stand-alone dental plans (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.18.100, 48.43.340,
					 48.43.715, 48.44.050, and 48.46.200. WSR 14-07-047 (Matter No. R 2013-27),
					 § 284-170-870, filed 3/13/14, effective
					 4/13/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-950 - Grandfathered health plan status (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-950, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-952 - Market conduct requirements related to grandfathered status (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-952, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-954 - Small group coverage market transition requirements (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-954, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-955 - Association health plan compliance with statutory or regulatory changes (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-955, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-958 - Transition of plans purchased by association members (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-958, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-170 - Health benefit plan management › Subchapter C - PROVIDER CONTRACTS AND PAYMENT › Section 284-170-959 - Individual coverage market transition requirements (Recodified)

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority: RCW  48.02.060, 48.43.700, 48.43.715,
					 48.44.050, 48.46.200, and  45 C.F.R. 150.101(2). WSR 14-01-039 (Matter No. R
					 2013-13), § 284-170-959, filed 12/11/13, effective
					 1/11/14.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter A - GENERAL PROVISIONS › Section 284-180-110 - Purpose

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
				this chapter is to establish uniform regulatory standards for health care
				benefit managers including, but not limited to, the processes and procedures
				for registration of health care benefit managers by the office of the insurance
				commissioner (commissioner).
(2)
				This chapter applies to all health care benefit managers except as otherwise
				expressly provided in this chapter. Health care benefit managers are
				responsible for compliance with the provisions of this chapter and are
				responsible for the compliance of any person or organization acting on behalf
				of or at the direction of the health care benefit manager, or acting pursuant
				to health care benefit manager standards or requirements. Carriers remain
				responsible for activities of health care benefit managers conducted on their
				behalf. A carrier may not offer as a defense to a violation of any provision of
				this chapter that the violation arose from the act or omission of a health care
				benefit manager or other person acting on behalf of or at the direction of a
				health care benefit manager.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter A - GENERAL PROVISIONS › Section 284-180-120 - Applicability and scope

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter
				applies to health care benefit managers as defined in RCW  48.200.020.
(2) This chapter does not apply to the
				actions of health care benefit managers providing services to, or acting on
				behalf of:
(a) Self-insured health plans;
(b) Medicare plans;
(c) Medicaid; and
(d) Union plans.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter A - GENERAL PROVISIONS › Section 284-180-150 - Severability

Current through Register Vol. 24-14, July 15, 2024
If any provision of this chapter or its application to any
				  person or circumstances is held invalid, the remainder of the chapter or its
				  application of the provision to other persons or circumstances is not
				  affected.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter B - REGISTRATION AND RENEWAL › Section 284-180-210 - Registration and renewal fees

Current through Register Vol. 24-14, July 15, 2024
(1) The
				commissioner must establish fees for registration and renewal in an amount that
				ensures the program for the registration, renewal, and oversight activities of
				the health care benefit managers is self-supporting. Each health care benefit
				manager must contribute a sufficient amount to the commissioner's regulatory
				account to pay for the reasonable costs, including overhead, of regulating
				health care benefit managers.
(2)
				The initial registration fee is $200.
(3) For the renewal fee, the commissioner
				will charge a proportional share of the annual cost of the insurance
				commissioner's renewal and oversight activities of health care benefit
				managers. Each health care benefit managers' proportional share of the program
				annual operating costs will be based on their Washington state annual gross
				income of their health care benefit manager business for the previous calendar
				year. The renewal fee is $500, at a minimum, and may increase based on a
				proportional share of each health care benefit managers gross income as
				reported to the insurance commissioner.
(4) If an unexpended balance of health care
				benefit manager registration and renewal funds remain in the insurance
				commissioner's regulatory account at the close of a fiscal year, the
				commissioner will carry the unexpended funds forward and use them to reduce
				future renewal fees.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter B - REGISTRATION AND RENEWAL › Section 284-180-220 - Health care benefit manager registration

Current through Register Vol. 24-14, July 15, 2024
(1) Beginning
				January 1, 2022, and thereafter, to conduct business in this state, health care
				benefit managers must register and have an approved registration with the
				commissioner.
(2) Health care
				benefit managers must apply for registration using the commissioner's
				electronic system, which is available at
www.insurance.wa.gov
.
(3) The registration period is valid from the
				date of approval of registration through June 30th of the same fiscal
				year.
(4) The registration
				application is not complete until the commissioner receives the complete
				registration form, any supporting documentation if required by the
				commissioner, and paid the $200 registration fee.
(5) A health care benefit manager may conduct
				business in this state after receiving notice of approval of the registration
				application from the commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter B - REGISTRATION AND RENEWAL › Section 284-180-230 - Health care benefit manager renewal

Current through Register Vol. 24-14, July 15, 2024
(1) Health care
				benefit managers annually renew their registrations and pay their renewal fee
				using the commissioner's electronic system, which is available at
www.insurance.wa.gov
.
(2) Health care benefit managers renewing
				their registrations must, no later than March 1st of each year, submit an
				electronic renewal report and supporting documents for approval to include:
(a) Their Washington state annual gross
				income for health care benefit manager business for the previous calendar year;
				and
(b) Any additional information,
				including supporting documents, as required by the commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter B - REGISTRATION AND RENEWAL › Section 284-180-240 - Providing and updating registration information

Current through Register Vol. 24-14, July 15, 2024
(1) When
				registering a health care benefit manager must apply with an affidavit
				affirming its accuracy. An application for registering as a health care benefit
				manager must provide for:
(a) The legal name
				as well as any additional names that it uses to conduct business;
(b) The names of persons and entities with
				any ownership or controlling interests, including stockholders, officers and
				directors, or limited liability company members, managers and officers in the
				health care benefit manager, and the identity of any entity for which the
				health care benefit manager has a controlling interest;
(c) A list of tax identification numbers and
				business licenses and registrations that are active;
(d) Identifying any areas of specialty, such
				as a pharmacy benefit management, radiology benefit management, laboratory
				benefit management, mental health care benefit management, or any other areas
				of specialty identified in the application;
(e) Contact information for communications
				regarding registration, renewal and oversight activities, to include name of
				the contact person, address, phone number, and valid email address;
(f) Name and contact information for the
				person the health care benefit manager has designated as responsible for
				compliance with state and federal laws to include name of the contact person,
				address, phone number, and valid email address;
(g) Identify if the health care benefit
				manager has committed any violations in this or any state or been the subject
				of an order from a any federal or state agency or court; and
(h) Any additional information requested by
				the commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter C - RECORDS AND NOTICES › Section 284-180-310 - Health care benefit manager records

Current through Register Vol. 24-14, July 15, 2024
(1) Health care benefit managers must
				maintain all records for a period of seven years from the date of creation and
				make them available to the commissioner upon request. Records include, but are
				not limited to:
(a) Registration and renewal
				materials that health care benefit managers submit to the commissioner to
				request registration and renewal; and
(b) Health care benefit managers that engage
				in pharmacy benefit management must also maintain information about appeals
				under chapter 48.200 RCW.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter C - RECORDS AND NOTICES › Section 284-180-320 - Deadline to provide copies of records

Current through Register Vol. 24-14, July 15, 2024
(1) If the commissioner requests records for
				inspection for a purpose other than to resolve an appeal under RCW  48.200.280,
				a health care benefit manager must make the records available to the
				commissioner within fifteen business days from the date on the written request.
				If the commissioner grants a written extension, then the records are due by the
				date indicated on the extension.
(2) Upon receipt of any inquiry from the
				commissioner concerning a complaint, every health care benefit manager must
				furnish the commissioner with an adequate response to the inquiry within
				fifteen business days after receipt of the commissioner's inquiry using the
				commissioner's electronic company complaint system.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter C - RECORDS AND NOTICES › Section 284-180-325 - Required notices

Current through Register Vol. 24-14, July 15, 2024
(1) Carriers
				must post on their website information that identifies each health care benefit
				manager contracted with the carrier and identify the services provided by the
				health care benefit manager. The information must be easy to find on the
				carriers' website with a link from the web page utilized for enrollees. The
				carrier is required to update the information on their website within thirty
				business days of any change, such as addition or removal of a health care
				benefit manager or a change in the services provided by a health care benefit
				manager.
(2) Carriers must notify
				enrollees in writing and at least annually, including at plan enrollment and
				renewal, of each health care benefit manager contracted with the carrier to
				provide any health care benefit management services. For example, written
				notices include disclosure in the policy or member handbook. This notice must
				identify the website address where enrollees can view an updated listing of all
				health care benefit managers utilized by the carrier.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter D - CONTRACT FILINGS › Section 284-180-405 - Definitions in this subchapter

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section apply throughout this
				  subchapter.
(1) "Complete filing"
				means a package of information containing forms, supporting information,
				documents and exhibits submitted to the commissioner electronically using the
				system for electronic rate and form filing (SERFF).
(2) "Date filed" means the date a complete
				filing has been received and accepted by the commissioner.
(3) "Filer" means:
(a) A person, organization or other entity
				that files forms or rates with the commissioner for a carrier or health care
				benefit manager; or
(b) A person
				employed by a carrier or heath care benefit manager to file under this
				chapter.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter D - CONTRACT FILINGS › Section 284-180-411 - Purpose of this subchapter

Current through Register Vol. 24-14, July 15, 2024
The purpose of this subchapter is to:
(1) Adopt processes and procedures for filers
				to use when submitting electronic forms and rates to the commissioner by way of
				SERFF.
(2) Designate SERFF as the
				method by which filers, including health care service contractors, health
				maintenance organizations, insurers as defined in
				RCW
				 48.01.050, and health care benefit managers
				must submit all health care benefit management contract forms to the
				commissioner.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter D - CONTRACT FILINGS › Section 284-180-415 - Scope of this subchapter

Current through Register Vol. 24-14, July 15, 2024
This subchapter applies to all carriers and health care
				  benefit managers that must file forms under chapter 48.200
				  RCW.
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter D - CONTRACT FILINGS › Section 284-180-421 - Filing instructions that are incorporated into this subchapter

Current through Register Vol. 24-14, July 15, 2024
SERFF is a dynamic application that the NAIC will revise and
				  enhance over time. To be consistent with NAIC filing standards and provide
				  timely instructions to filers, the commissioner will incorporate documents
				  posted on the SERFF website into this chapter. By reference, the commissioner
				  incorporates these documents into this chapter:
(1) The
SERFF Industry
				Manual
available within the SERFF application; and
(2) The
Washington State SERFF Health
				Care Benefit Management General Filing Instructions
posted on the
				commissioner's website (
www.insurance.wa.gov
).
Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter D - CONTRACT FILINGS › Section 284-180-425 - General health care benefit management form filing rules

Current through Register Vol. 24-14, July 15, 2024
(1) Each health
				care benefit management contract form and contract amendment form filing must
				be submitted to the commissioner electronically using SERFF.
(a) Every form filed in SERFF must:
(i) Be attached to the form schedule; and
(ii) Have a unique identifying
				number and a way to distinguish it from other versions of the same
				form.