Wash. Admin. Code § 284-43A-140 - External review of adverse benefit determinations
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.
(5) A carrier may waive a requirement that
internal appeals must be exhausted before an appellant may proceed to an
independent review of an adverse determination.
(6) Upon receipt of the information provided
by the appellant to the IRO pursuant to
RCW
48.43.535 and this section, a carrier may
reverse its final internal adverse determination. If it does so, it must
immediately notify the IRO and the appellant.
(7) Carriers must report to the commissioner
each assignment made to an IRO not later than one business day after an
assignment is made. Information regarding the enrollee's personal health may
not be provided with the report.
(8) Each carrier and health plan must submit
final independent review organization (IRO) decision determination information
to the commissioner's online service within three business days of receipt of
the IRO's final decision. Data elements and procedures for submission are
located on the office of the insurance commissioner's web site.
(9) The requirements of this section are in
addition to the requirements set forth in
RCW
48.43.535, and rules adopted in subchapter B
of this chapter.
Notes
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