Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter D - PRIOR AUTHORIZATION AND UTILIZATION REVIEW › Section 284-43-2022 - Time frame for exception and substitution request determinations

Current through Register Vol. 24-14, July 15, 2024
(1) A carrier must
				make an exception request determination in a timely manner as defined in this
				section. A carrier may not deny the exception request if the enrollee or
				provider does not receive a response to an exception request within the time
				frames in this section.
(2) A
				carrier must maintain a sufficient record of each exception request to
				establish its compliance with the required exception process and time frames
				under chapter 284-43 WAC and
				RCW
				 48.43.420. Upon the commissioner's request, a
				carrier must make all records and documentation available and produce all
				requested documentation from any entity providing benefit administration or
				exception request decisions on its behalf within the time frame set by the
				commissioner.
(3) If a provider
				fails to submit sufficient information for the carrier to approve or deny an
				exception request, a carrier must notify the provider of the specific
				information needed within three business days of receiving a nonurgent
				exception request and one business day of receiving an urgent exception
				request. A carrier must notify the provider that the documentation is
				insufficient and must explain what information is missing. A carrier may
				establish a specific reasonable time frame for submission of the additional
				information. This time frame must be communicated to the provider or enrollee
				with a carrier's request for additional information. If the additional
				information is not received within that time frame, a carrier may deny the
				request.
(4) When a carrier
				receives sufficient information to make a decision regarding a nonurgent
				exception request, a carrier must make its determination and notify the
				enrollee or the enrollee's designee and the prescribing provider (or other
				prescriber, as appropriate) no later than three business days following receipt
				of the request.
(5) When a carrier
				receives sufficient information to make a decision regarding an urgent
				exception request, a carrier must make its determination and notify the
				enrollee or the enrollee's designee and the prescribing provider (or other
				pre-scriber, as appropriate) no later than one business day following receipt
				of the request.
(6) Use of a
				carrier's exception process is not a grievance or appeal pursuant to
				RCW
				 48.43.530 and
				48.43.535.
				Denial of an exception request is an adverse benefit determination, and an
				enrollee, their representative provider or facility, or representative may
				request review of that decision using a carrier's appeal or adverse benefit
				determination review process.
(7) A
				carrier's denial of an exception request is subject to the requirements of
				RCW
				 48.43.535 and chapter 284-43A WAC, which
				grants enrollees access to independent external review of carrier decisions to
				deny, modify, reduce or terminate coverage of or payment for a health care
				service or if the carrier exceeds the timelines for making an exception request
				decision and denies coverage. While the external review is conducted, the
				carrier must cover the drug if the exception request was urgent or was for an
				emergency fill. If such an exigency ceases, any drug previously covered under
				such exigency may only be reauthorized through the standard exception request
				process. If the independent external review reverses the carrier's denial of
				either an urgent or nonurgent exception request, the carrier must
				retrospectively cover the nonformulary drug and continue coverage for the
				duration of the prescription.
(8) A
				carrier may not penalize or threaten a provider with a reduction in future
				payment or termination of a participating provider agreement because the
				provider disputes a carrier's determination with respect to coverage or payment
				for a substitute drug.