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-140 - External review of adverse benefit determinations

Current through Register Vol. 24-14, July 15, 2024
When the internal review of an adverse benefit determination
				  is final, or is deemed exhausted, the appellant may request an external
				  independent review of the final internal adverse benefit determination.
				  Carriers and health plans must inform appellants of their right to external
				  independent review, and explain the process to exercise that right. If the
				  appellant requests an external independent review of a final internal adverse
				  determination, the carrier or health plan must cooperatively participate in
				  that review.
(1) Appellants must be
				provided the right to external review of adverse benefit determinations based
				on medical necessity, appropriateness, health care setting, level of care, or
				that the requested service or supply is not efficacious or otherwise
				unjustified under evidence-based medical criteria. The carrier may not
				establish a minimum dollar amount restriction as a predicate for an appellant
				to seek external independent review.
(2) Carriers must use the rotational registry
				system of certified independent review organizations (IRO) established by the
				commissioner, and must select reviewing IROs in the rotational manner described
				in the rotational registry system, using the commissioner's online service. 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.
(3) The rotational
				registry system, a current list of certified IROs, IRO assignment instructions,
				and an IRO assignment form to be used by carriers, are available on the
				insurance commissioner's web site (
www.insurance.wa.gov
).
(4) In addition to the requirements set forth
				in RCW
				 48.43.535, the carrier and health plan must:
(a) Make available to the appellant and to
				any provider acting on behalf of the appellant all materials provided to an IRO
				reviewing the carrier's determination;
(b) Provide IRO review without imposing any
				cost to the appellant or their provider;
(c) 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.
(d) Within one day of selecting the IRO,
				notify the appellant of the name of the IRO and its contact information. This
				requirement is intended to comply with the federal standard that appellants
				receive notice of the IRO's identity and contact information within one day of
				assignment. The notice from the carrier must explain that the IRO will accept
				additional information in writing from the appellant for up to five business
				days after it receives the assignment. The IRO must consider this information
				when conducting its review.