Contract may not contain a “discretionary clause” that purports to WAC 284-44-015 reserve discretion to a carrier or its designees to interpret the contract or decide eligibility for benefits, or requires deference to such interpretations or decisions. WAC 284-44-015 Specific prohibited provisions: That the carrier's interpretation of the terms of the contract is (1)(a) binding; That the carrier's decision regarding eligibility or continued WAC 284-44-015 receipt of benefits is binding; (1)(b) That the carrier's decision to deny, modify, reduce or terminate WAC 284-44-015 payment, coverage, authorization, or provision of health care (1)(c) service or benefits, is binding; That is no appeal or judicial remedy from a claim denial; (1)(d) That deference must be given to the carrier's interpretation of WAC the contract or claim decision; and That the standard of review of a carrier's interpretation of the WAC contract or claim decision is other than a de novo review.
WAC 284-44-015 Contract may not contain a “discretionary clause” that purports to reserve discretion to a carrier or its designees to interpret the contract or decide eligibility for benefits, or requires deference to such interpretations or decisions. WAC 284-44-015 (1)(a) Specific prohibited provisions: That the carrier's interpretation of the terms of the contract is binding; WAC 284-44-015 (1)(b) That the carrier's decision regarding eligibility or continued receipt of benefits is binding; WAC 284-44-015 (1)(c) That the carrier's decision to deny, modify, reduce or terminate payment, coverage, authorization, or provision of health care service or benefits, is binding; (1)(d) That is no appeal or judicial remedy from a claim denial; WAC That deference must be given to the carrier's interpretation of the contract or claim decision; and WAC That the standard of review of a carrier's interpretation of the contract or claim decision is other than a de novo review.