Washington Code 48.43.016 – Utilization management standards and criteria — Health carrier requirements — Definitions
Current as of: 2023 | Check for updates
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(1) A health carrier or its contracted entity that imposes different prior authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession in the same health plan shall inform an enrollee which tier an individual provider or group of providers is in by posting the information on its website in a manner accessible to both enrollees and providers.
Terms Used In Washington Code 48.43.016
- Fraud: Intentional deception resulting in injury to another.
- person: may be construed to include the United States, this state, or any state or territory, or any public or private corporation or limited liability company, as well as an individual. See Washington Code 1.16.080
(2)(a) A health carrier or its contracted entity may not require utilization management or review of any kind including, but not limited to, prior, concurrent, or postservice authorization for an initial evaluation and management visit and up to six treatment visits with a contracting provider in a new episode of care for each of the following: Chiropractic, physical therapy, occupational therapy, acupuncture and Eastern medicine, massage therapy, or speech and hearing therapies. Visits for which utilization management or review is prohibited under this section are subject to quantitative treatment limits of the health plan. Notwithstanding RCW 48.43.515(5) this section may not be interpreted to limit the ability of a health plan to require a referral or prescription for the therapies listed in this section.
(b) For visits for which utilization management or review is prohibited under this section, a health carrier or its contracted entity may not:
(i) Deny or limit coverage on the basis of medical necessity or appropriateness; or
(ii) Retroactively deny care or refuse payment for the visits.
(3) A health carrier shall post on its website and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions.
(4) A health care provider with whom a health carrier consults regarding a decision to deny, limit, or terminate a person’s covered health care services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the health care provider being reviewed or of a specialty whose practice entails the same or similar covered health care service.
(5) A health carrier may not require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party.
(6) Nothing in this section prevents a health carrier from denying coverage based on insurance fraud.
(7) For purposes of this section:
(a) “New episode of care” means treatment for a new condition or diagnosis for which the enrollee has not been treated by a provider of the same licensed profession within the previous ninety days and is not currently undergoing any active treatment.
NOTES:
Intent—2020 c 193: “The legislature intends to facilitate patient access to appropriate therapies for newly diagnosed health conditions while recognizing the necessity for health carriers to employ reasonable utilization management techniques.” [ 2020 c 193 § 1.]
Findings—2019 c 308: See note following RCW 18.06.010.
Effective date—2015 c 251: See note following RCW 41.05.074.