48.200.280 – Predetermination of reimbursement costs—Appeals—Review by commissioner.
RCW 48.200.280 Predetermination of reimbursement costs—Appeals—Review by commissioner. (1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise. (a) “List” means the list of drugs for which predetermined reimbursement costs have been established, such as a maximum allowable cost or maximum allowable cost list or any other benchmark prices […]
48.200.290 – Enforcement—Disputes—Civil penalties.
RCW 48.200.290 Enforcement—Disputes—Civil penalties. (1) The commissioner shall have enforcement authority over this chapter and shall have authority to render a binding decision in any dispute between a pharmacy benefit manager, or third-party administrator of prescription drug benefits, and a pharmacy arising out of an appeal under RCW 48.200.280(6) regarding drug pricing and reimbursement. (2) […]
48.200.050 – Inquiries or complaints—Violations of chapter—Enforcement actions—Responsibility of carriers and programs for compliance.
RCW 48.200.050 Inquiries or complaints—Violations of chapter—Enforcement actions—Responsibility of carriers and programs for compliance. (1) Upon notifying a carrier or health care benefit manager of an inquiry or complaint filed with the commissioner pertaining to the conduct of a health care benefit manager identified in the inquiry or complaint, the commissioner must provide notice of […]
48.200.210 – Definitions applicable to RCW 48.200.220 through 48.200.290.
RCW 48.200.210 Definitions applicable to RCW 48.200.220 through 48.200.290. The definitions in this section apply throughout this section and RCW 48.200.220 through 48.200.290 unless the context clearly requires otherwise. (1) “Audit” means an on-site or remote review of the records of a pharmacy by or on behalf of an entity. (2) “Claim” means a request […]
48.200.220 – Auditing of claims—Requirements—Prohibited practices.
RCW 48.200.220 Auditing of claims—Requirements—Prohibited practices. An entity that audits claims or an independent third party that contracts with an entity to audit claims: (1) Must establish, in writing, a procedure for a pharmacy to appeal the entity’s findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, […]
48.200.230 – Basis of finding of claim.
RCW 48.200.230 Basis of finding of claim. An entity’s finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation, or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions […]
48.200.240 – Contract with third party—Prohibited practices.
RCW 48.200.240 Contract with third party—Prohibited practices. An entity that contracts with an independent third party to conduct audits may not: (1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or (2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject […]
48.200.250 – Evidence of validation of claim.
RCW 48.200.250 Evidence of validation of claim. For purposes of RCW 48.200.210 through 48.200.270, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim: (1) An electronic or physical copy of a valid prescription if the prescribed drug was, within fourteen […]
48.195.020 – Annual disclosure—Lead state when insurer part of insurance group—Additional information may be required.
RCW 48.195.020 Annual disclosure—Lead state when insurer part of insurance group—Additional information may be required. (1) An insurer, or the insurance group of which the insurer is a member, must, no later than June 1st of each calendar year, submit to the commissioner a corporate governance annual disclosure that contains the information described in RCW […]
48.195.030 – Responses to annual disclosure inquiries—Documentation and supporting information.
RCW 48.195.030 Responses to annual disclosure inquiries—Documentation and supporting information. (1) The insurer or insurance group has discretion over the responses to the corporate governance annual disclosure inquiries, provided the corporate governance annual disclosure contains the material information necessary to permit the commissioner to gain an understanding of the insurer’s or insurance group’s corporate governance […]