RCW 48.43.757
Health care provider credentialing applications—Reimbursement requirements.
(1) If a carrier approves a health care provider's credentialing application, upon completion of the credentialing process, the carrier must reimburse a health care provider under the following circumstances:
(a) When credentialing a new health care provider through a new provider contract, the carrier must reimburse the health care provider for covered services provided to the carrier's enrollee retroactively to the date of contract effectiveness if the credentialing process extends beyond the effective date of the new contract.
(b) When credentialing a provider to be added to an approved and in-use provider contract where a relationship existed between the carrier and the health care provider or the entity for whom the health care provider is employed or engaged at the time the health care provider submitted the completed credentialing application, the carrier must reimburse the health care provider for covered health care services provided to the carrier's enrollees during the credentialing process beginning when the health care provider submitted a completed credentialing application to the carrier.
(2) The health carrier must reimburse the health care provider at the contracted rate for the applicable health benefit plan that the health care provider would have been paid at the time the services were provided if the health care provider were fully credentialed by the carrier.
(3) Nothing in this section requires reimbursement of health care provider-rendered services that are not benefits or services covered by the health carrier's health benefit plan.
(4) Nothing in this section requires a health carrier to pay reimbursement for any covered medical services provided by a health care provider applicant if the health care provider's credentialing application is not approved or if the carrier and health care provider do not enter into a contractual relationship.
[ 2020 c 4 § 2.]
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.