RCW 48.43.600
Overpayment recovery—Carrier.
(1) Except in the case of fraud, or as provided in subsections (2) and (3) of this section, a carrier may not: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(2) A carrier may not, if doing so for reasons related to coordination of benefits with another carrier or entity responsible for payment of a claim: (a) Request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within thirty months after the date that the payment was made; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund, and include the name and mailing address of the entity that has primary responsibility for payment of the claim. If a provider fails to contest the request in writing to the carrier within thirty days of its receipt, the request is deemed accepted and the refund must be paid.
(3) A carrier may at any time request a refund from a health care provider of a payment previously made to satisfy a claim if: (a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law, such as tort liability; and (b) the carrier is unable to recover directly from the third party because the third party has either already paid or will pay the provider for the health services covered by the claim.
(4) If a contract between a carrier and a health care provider conflicts with this section, this section shall prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a carrier any payment previously made to satisfy a claim.
(5) For purposes of this section, "refund" means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider.
(6) This section neither permits nor precludes a carrier from recovering from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy, or other benefit agreement.
(7) This section does not apply to claims for health care services provided through dental only health carriers, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter 48.66 RCW.
[ 2005 c 278 § 1.]
NOTES:
Application—2005 c 278: "This act applies to contracts issued or renewed on or after January 1, 2006." [ 2005 c 278 § 3.]
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.