48.43.904 – Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.
RCW 48.43.904 Construction—Chapter applicable to state registered domestic partnerships—2009 c 521. For the purposes of this chapter, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family shall be interpreted as applying equally to state registered domestic partnerships or individuals in state registered domestic partnerships as well as to marital relationships […]
48.43.517 – Enrollment of child participating in medical assistance program—Employer-sponsored health plan.
RCW 48.43.517 Enrollment of child participating in medical assistance program—Employer-sponsored health plan. When the health care authority has determined that it is cost-effective to enroll a child participating in a medical assistance program under chapter 74.09 RCW in an employer-sponsored health plan, the carrier shall permit the enrollment of the participant who is otherwise eligible […]
48.43.520 – Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules.
RCW 48.43.520 Requirement to maintain a documented utilization review program description and written utilization review criteria—Rules. (1) Carriers that offer a health plan shall maintain a documented utilization review program description and written utilization review criteria based on reasonable medical evidence. The program must include a method for reviewing and updating criteria. Carriers shall make […]
48.43.525 – Prohibition against retrospective denial of health plan coverage—Rules.
RCW 48.43.525 Prohibition against retrospective denial of health plan coverage—Rules. (1) A health carrier that offers a health plan shall not retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan’s written policies at the time the care was rendered. (2) The commissioner shall adopt, in rule, standards for this […]
48.43.530 – Requirement for carriers to have comprehensive grievance and appeal processes—Carrier’s duties—Procedures—Appeals—Rules.
RCW 48.43.530 Requirement for carriers to have comprehensive grievance and appeal processes—Carrier’s duties—Procedures—Appeals—Rules. (1) Each carrier and health plan must have fully operational, comprehensive grievance and appeal processes, and for plans that are not grandfathered, fully operational, comprehensive, and effective grievance and review of adverse benefit determination processes that comply with the requirements of this […]
48.43.535 – Independent review of health care disputes—System for using certified independent review organizations—Rules.
RCW 48.43.535 Independent review of health care disputes—System for using certified independent review organizations—Rules. (1) There is a need for a process for the fair consideration of disputes relating to decisions by carriers that offer a health plan to deny, modify, reduce, or terminate coverage of or payment for health care services for an enrollee. […]
48.43.537 – Health care disputes—Certifying independent review organizations—Application—Restrictions—Maximum fee schedule for conducting reviews—Rules.
RCW 48.43.537 Health care disputes—Certifying independent review organizations—Application—Restrictions—Maximum fee schedule for conducting reviews—Rules. (1) No later than January 1, 2017, the insurance commissioner shall adopt rules providing a procedure and criteria for certifying one or more organizations to perform independent review of health care disputes described in RCW 48.43.535. (2) The rules must require that […]
48.43.540 – Requirement to designate a licensed medical director—Exemption.
RCW 48.43.540 Requirement to designate a licensed medical director—Exemption. Any carrier that offers a health plan and any self-insured health plan subject to the jurisdiction of Washington state shall designate a medical director who is licensed under chapter 18.57 or 18.71 RCW. However, a naturopathic or complementary alternative health plan, which provides solely complementary alternative […]
48.43.545 – Standard of care—Liability—Causes of action—Defense—Exception.
RCW 48.43.545 Standard of care—Liability—Causes of action—Defense—Exception. (1)(a) A health carrier shall adhere to the accepted standard of care for health care providers under chapter 7.70 RCW when arranging for the provision of medically necessary health care services to its enrollees. A health carrier shall be liable for any and all harm proximately caused by […]
48.43.550 – Delegation of duties—Carrier accountability.
RCW 48.43.550 Delegation of duties—Carrier accountability. Each carrier is accountable for and must oversee any activities required by chapter 5, Laws of 2000 that it delegates to any subcontractor. No contract with a subcontractor executed by the health carrier or the subcontractor may relieve the health carrier of its obligations to any enrollee for the […]