Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43 - Health carriers and health plans › Subchapter E - ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS › Section 284-43-3110 - Internal review of adverse benefit determinations

Current through Register Vol. 24-14, July 15, 2024
An appellant seeking review of an adverse benefit
				  determination must use the carrier's review process. Each carrier must include
				  the opportunity for internal review of an adverse benefit determination in its
				  review process. Treating providers may seek expedited review on a patient's
				  behalf, regardless of whether the provider is affiliated with the carrier on a
				  contracted basis.
(1) When a carrier
				receives a written request for review, the carrier must reconsider the adverse
				benefit determination. The carrier must notify the appellant of the review
				decision within fourteen days of receipt of the request for review, unless the
				adverse benefit determination involves an experimental or investigational
				treatment. The carrier must notify the appellant of the review decision within
				twenty days of receipt of the request for review when the adverse benefit
				determination involves an experimental or investigational treatment.
(2) For good cause, a carrier may extend the
				time it takes to make a review determination by up to sixteen additional days
				without the appellant's written consent, and must notify appellant of the
				extension and the reason for the extension. The carrier may request further
				extension of its response time only if the appellant consents to a specific
				request for a further extension, the consent is reduced to writing, and
				includes a specific agreed-upon date for determination. In its request for the
				appellant's consent, the carrier must explain that waiver of the response time
				is not compulsory.
(3) The carrier
				must provide the appellant with any new or additional evidence or rationale
				considered, whether relied upon, generated by, or at the direction of the
				carrier in connection with the claim. The evidence or rationale must be
				provided free of charge to the appellant and sufficiently in advance of the
				date the notice of final internal review must be provided. The purpose of this
				requirement is to ensure the appellant has a reasonable opportunity to respond
				prior to that date. If the appellant requests an extension in order to respond
				to any new or additional rationale or evidence, the carrier and health plan
				must extend the determination date for a reasonable amount of time, which may
				not be less than two days.
(4) A
				carrier's review process must provide the appellant with the opportunity to
				submit information, documents, written comments, records, evidence, and
				testimony, including information and records obtained through a second opinion.
				An appellant has the right to review the carrier and health plan's file and
				obtain a free copy of all documents, records, and information relevant to any
				claim that is the subject of the determination being appealed.
(5) The internal review process must include
				the requirement that the carrier affirmatively review and investigate the
				appealed determination, and consider all information submitted by the appellant
				prior to issuing a determination.
(6) Review of adverse determinations must be
				performed by health care providers or staff who were not involved in the
				initial decision, and who are not subordinates of the persons involved in the
				initial decision. If the determination involves, even in part, medical
				judgment, the reviewer must be or must consult with a health care professional
				who has appropriate training and experience in the field of medicine
				encompassing the appellant's condition or disease and make a determination that
				is within the clinical standard of care for an appellant's disease or
				condition.
(7) The internal review
				process for group health plans may be administered so that an appellant must
				file two internal requests for review prior to bringing a civil action. For
				individual health plans, a carrier must provide for only one level of internal
				review before issuing a final determination, and may not require two levels of
				internal review.
(8) A rescission
				of coverage is an adverse benefit determination for which review may be
				requested.
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), § 284-43-525, filed
					 11/7/12, effective 11/20/12.