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 the organization ensure:
(a) The confidentiality of medical records transmitted to an independent review organization for use in independent reviews;
(b) That each health care provider, physician, or contract specialist making review determinations for an independent review organization is qualified. Physicians, other health care providers, and, if applicable, contract specialists must be appropriately licensed, certified, or registered as required in Washington state or in at least one state with standards substantially comparable to Washington state. Reviewers may be drawn from nationally recognized centers of excellence, academic institutions, and recognized leading practice sites. Expert medical reviewers should have substantial, recent clinical experience dealing with the same or similar health conditions. The organization must have demonstrated expertise and a history of reviewing health care in terms of medical necessity, appropriateness, and the application of other health plan coverage provisions;
(c) That any physician, health care provider, or contract specialist making a review determination in a specific review is free of any actual or potential conflict of interest or bias. Neither the expert reviewer, nor the independent review organization, nor any officer, director, or management employee of the independent review organization may have any material professional, familial, or financial affiliation with any of the following: The health carrier; professional associations of carriers and providers; the provider; the provider's medical or practice group; the health facility at which the service would be provided; the developer or manufacturer of a drug or device under review; or the enrollee;
(d) The fairness of the procedures used by the independent review organization in making the determinations;
(e) That each independent review organization make its determination:
(i) Not later than the earlier of:
(A) The fifteenth day after the date the independent review organization receives the information necessary to make the determination; or
(B) The twentieth day after the date the independent review organization receives the request that the determination be made. In exceptional circumstances, when the independent review organization has not obtained information necessary to make a determination, a determination may be made by the twenty-fifth day after the date the organization received the request for the determination; and
(ii) In requests for expedited review under RCW 48.43.535(7)(a), as expeditiously as possible but within not more than seventy-two hours after the date the independent review organization receives the request for expedited review;
(f) That timely notice is provided to enrollees of the results of the independent review, including the clinical basis for the determination;
(g) That the independent review organization has a quality assurance mechanism in place that ensures the timeliness and quality of review and communication of determinations to enrollees and carriers, and the qualifications, impartiality, and freedom from conflict of interest of the organization, its staff, and expert reviewers; and
(h) That the independent review organization meets any other reasonable requirements of the insurance commissioner directly related to the functions the organization is to perform under this section and RCW 48.43.535, and related to assessing fees to carriers in a manner consistent with the maximum fee schedule developed under this section.
(3) To be certified as an independent review organization under this chapter, an organization must submit to the insurance commissioner an application in the form required by the insurance commissioner. The application must include:
(a) For an applicant that is publicly held, the name of each stockholder or owner of more than five percent of any stock or options;
(b) The name of any holder of bonds or notes of the applicant that exceed one hundred thousand dollars;
(c) The name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control;
(d) The name and a biographical sketch of each director, officer, and executive of the applicant and any entity listed under (c) of this subsection and a description of any relationship the named individual has with:
(i) A carrier;
(ii) A utilization review agent;
(iii) A nonprofit or for-profit health corporation;
(iv) A health care provider;
(v) A drug or device manufacturer; or
(vi) A group representing any of the entities described by (d)(i) through (v) of this subsection;
(e) The percentage of the applicant's revenues that are anticipated to be derived from reviews conducted under RCW 48.43.535;
(f) A description of the areas of expertise of the health care professionals and contract specialists making review determinations for the applicant; and
(g) The procedures to be used by the independent review organization in making review determinations regarding reviews conducted under RCW 48.43.535.
(4) If at any time there is a material change in the information included in the application under subsection (3) of this section, the independent review organization shall submit updated information to the insurance commissioner.
(5) An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a carrier or a trade or professional association of health care providers or carriers.
(6) An independent review organization, and individuals acting on its behalf, are immune from suit in a civil action when performing functions under chapter 5, Laws of 2000. However, this immunity does not apply to an act or omission made in bad faith or that involves gross negligence.
(7) Independent review organizations must be free from interference by state government in its functioning except as provided in subsection (8) of this section.
(8) The rules adopted under this section shall include provisions for terminating the certification of an independent review organization for failure to comply with the requirements for certification. The insurance commissioner may review the operation and performance of an independent review organization in response to complaints or other concerns about compliance. The rules adopted under this section must include a reasonable maximum fee schedule that independent review organizations shall use to assess carriers for conducting reviews authorized under RCW 48.43.535.
(9) In adopting rules for this section, the insurance commissioner shall take into consideration rules adopted by the department of health that regulate independent review organizations and standards for independent review organizations adopted by national accreditation organizations. The insurance commissioner may accept national accreditation or certification by another state as evidence that an organization satisfies some or all of the requirements for certification by the insurance commissioner as an independent review organization.
(10) The rules adopted under this section must require independent review organizations to report decisions and associated information directly to the insurance commissioner.
[ 2016 c 139 § 1; 2012 c 211 § 14; 2005 c 54 § 1; 2000 c 5 § 12. Formerly RCW 43.70.235.]
NOTES:
Savings clause—Automatic certification—2016 c 139: "(1) Independent review organizations remain subject to RCW 48.43.537, as it existed on January 1, 2016, and the rules adopted by the department of health under that section through December 31, 2016. Beginning on January 1, 2017, the insurance commissioner is the sole certifying authority for independent review organizations under RCW 48.43.537.
(2) On January 1, 2017, the insurance commissioner shall automatically certify each independent review organization that was certified in good standing by the department of health on December 31, 2016." [ 2016 c 139 § 2.]
Intent—Purpose—2000 c 5: See RCW 48.43.500.
Application—Short title—Captions not law—Construction—Severability—Application to contracts—Effective dates—2000 c 5: See notes following RCW 48.43.500.
Structure Revised Code of Washington
Chapter 48.43 - Insurance Reform.
48.43.008 - Enrollment in employer-sponsored health plan—Person eligible for medical assistance.
48.43.009 - Health care sharing ministries.
48.43.012 - Health plans—Preexisting conditions—Rules.
48.43.01211 - Health plans—Eligibility—Health status-related factors—Rules.
48.43.0123 - Health plans—Rescission of coverage—Rules.
48.43.0124 - Health plans—Cost sharing for essential health benefits—Rules.
48.43.0125 - Essential health benefits—Annual or lifetime dollar limits.
48.43.0127 - Group health plans—Waiting period—Rules.
48.43.016 - Utilization management standards and criteria—Health carrier requirements—Definitions.
48.43.021 - Personally identifiable health information—Restrictions on release.
48.43.022 - Enrollee identification card—Social security number restriction.
48.43.023 - Pharmacy identification cards—Rules.
48.43.028 - Eligibility to purchase certain health benefit plans—Small employers and small groups.
48.43.035 - Group health benefit plans—Guaranteed issue and continuity of coverage—Exceptions.
48.43.038 - Individual health plans—Guarantee of continuity of coverage—Exceptions.
48.43.041 - Individual health benefit plans—Mandatory benefits.
48.43.043 - Colorectal cancer examinations and laboratory tests—Required benefits or coverage.
48.43.045 - Health plan requirements—Annual reports—Exemptions.
48.43.047 - Health plans—Minimum coverage for preventative services—No cost-sharing requirements.
48.43.055 - Procedures for review and adjudication of health care provider complaints—Requirements.
48.43.059 - Payments made by a second-party payment process—Definition.
48.43.0725 - Reproductive health plan coverage—Immediate postpartum contraception devices.
48.43.073 - Required abortion coverage—Limitations.
48.43.081 - Anatomic pathology services—Payment for services—Definitions.
48.43.083 - Chiropractor services—Participating provider agreement—Health carrier reimbursement.
48.43.091 - Health carrier coverage of outpatient mental health services—Requirements.
48.43.093 - Health carrier coverage of emergency medical services—Requirements—Conditions.
48.43.094 - Pharmacist provided services—Health plan requirements.
48.43.097 - Filing of financial statements—Every health carrier.
48.43.105 - Preparation of documents that compare health carriers—Immunity—Due diligence.
48.43.125 - Coverage at a long-term care facility following hospitalization—Definition.
48.43.176 - Eosinophilic gastrointestinal associated disorder—Elemental formula.
48.43.180 - Denturist services.
48.43.185 - General anesthesia services for dental procedures.
48.43.190 - Payment of chiropractic services—Parity.
48.43.195 - Contraceptive drugs—Twelve-month refill coverage.
48.43.200 - Disclosure of certain material transactions—Report—Information is confidential.
48.43.205 - Material acquisitions or dispositions.
48.43.210 - Asset acquisitions—Asset dispositions.
48.43.215 - Report of a material acquisition or disposition of assets—Information required.
48.43.220 - Material nonrenewals, cancellations, or revisions of ceded reinsurance agreements.
48.43.600 - Overpayment recovery—Carrier.
48.43.605 - Overpayment recovery—Health care provider.
48.43.650 - Fixed payment insurance products—Commissioner's annual report.
48.43.670 - Plan or contract renewal—Modification of wellness program.
48.43.680 - Lifetime limit on transplants—Definition.
48.43.690 - Assessments under RCW 70.290.040 considered medical expenses.
48.43.700 - Exchange—Plans that a carrier must offer—Review—Rules.
48.43.705 - Plans offered outside of exchange.
48.43.710 - Certification as qualified health plan not an exemption.
48.43.720 - Reinsurance and risk adjustment programs—Affordable care act—Rules.
48.43.733 - Rates and forms of group health benefit plans—Timing of filings—Exceptions—Rules.
48.43.734 - Health carrier rate filings—Review of surplus, capital, and profit levels.
48.43.740 - Dental only plan—Emergency dental conditions—Definitions.
48.43.743 - Dental only plan—Annual data statement—Contents—Public use—Definition.
48.43.755 - Health care provider credentialing applications—Use of electronic database by providers.
48.43.757 - Health care provider credentialing applications—Reimbursement requirements.
48.43.760 - Opioid use disorder—Coverage without prior authorization.
48.43.762 - Opioid overdose reversal medication bulk purchasing and distribution program.
48.43.765 - Health carrier network adequacy—Mental health and substance abuse treatment.
48.43.770 - Individual market health plan availability—Annual report.
48.43.775 - Qualified health plan participation—Reimbursement rate for other health plans.
48.43.780 - Insulin drugs—Cap on enrollee's required payment amount—Cost-sharing requirements.
48.43.785 - COVID-19 personal protective equipment expenses—Health care provider reimbursement.
48.43.790 - Behavioral services—Next-day appointments.
48.43.795 - Qualified health plans—Acceptance of premium and cost-sharing assistance.
48.43.800 - Primary care expenditures assessment—Review.
48.43.805 - Prescription drug upper payment limit—Rules.
48.43.810 - Biomarker testing—Standards—Construction.
48.43.815 - Donor human milk—Standards.
48.43.820 - Consolidated appropriations act enforcement—Implementation of federal regulations.
48.43.320 - Authorized control level event—Commissioner's options.
48.43.325 - Mandatory control level event—Commissioner's duty—Regulatory control.
48.43.330 - Carrier's right to hearing—Request by carrier—Date set by commissioner.
48.43.340 - Powers or duties of commissioner not limited—Rules.
48.43.350 - No liability or cause of action against commissioner or department.
48.43.355 - Notice by commissioner to carrier—When effective.
48.43.360 - Initial RBC reports—Calculation of initial RBC levels—Subsequent reports.
48.43.366 - Self-funded multiple employer welfare arrangements.
48.43.370 - RBC standards not applicable to certain carriers.
48.43.400 - Prescription drug utilization management—Definitions.
48.43.430 - Prescription medication—Maximum charge at point of sale—Requirements.
48.43.435 - Prescription medication—Cost-sharing calculation—Application—Rules.
48.43.500 - Intent—Purpose—2000 c 5.
48.43.515 - Access to appropriate health services—Enrollee options—Rules.
48.43.525 - Prohibition against retrospective denial of health plan coverage—Rules.
48.43.540 - Requirement to designate a licensed medical director—Exemption.
48.43.545 - Standard of care—Liability—Causes of action—Defense—Exception.
48.43.550 - Delegation of duties—Carrier accountability.
48.43.902 - Effective date—1996 c 312.
48.43.904 - Construction—Chapter applicable to state registered domestic partnerships—2009 c 521.