Washington, whether the services are under continued scientific testing and research, whether the services show a demonstrable benefit for a particular illness or disease, and whether they are proven to be safe and efficacious." WAC "In determining whether services are experimental or 284-46-507(2)(b) investigational, the plan will consider whether the services result in greater benefits for a particular illness or disease than other generally available services, and do not pose a significant risk to health or safety of the patient." Support for WAC The supporting documentation upon which the criteria are Criteria Must 284-46-507(2)(b) established must be made available for inspection upon written be Available request in all instances and may not be withheld as proprietary. Experimental or Time Limits for WAC Whether the claim or request for preauthorization is made in writing Investigational Denial or through other claim presentation or preauthorization procedures Treatment WAC set out in the contract, any denial because of an experimental or (Cont’d) investigational exclusion or limitation, must be done in writing within twenty working days of receipt of a fully documented request. The issuer may extend the review period beyond twenty days only with the informed written consent of the enrollee. Grievance Definition RCW 48.43.005 means a written complaint submitted by or on behalf of Procedures (21) an enrollee regarding service delivery issues other than denial of WAC payment for, or nonprovision of, medical services, including (11) dissatisfaction with medical care, waiting time for medical services, WAC provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier. 48.43.530(8) Contract must provide a clear explanation of the grievance process.
Washington, whether the services are under continued scientific testing and research, whether the services show a demonstrable benefit for a particular illness or disease, and whether they are proven to be safe and efficacious." WAC 284-46-507(2)(b) "In determining whether services are experimental or investigational, the plan will consider whether the services result in greater benefits for a particular illness or disease than other generally available services, and do not pose a significant risk to health or safety of the patient." Support for Criteria Must be Available WAC 284-46-507(2)(b) The supporting documentation upon which the criteria are established must be made available for inspection upon written request in all instances and may not be withheld as proprietary. Experimental or Investigational Treatment (Cont’d) Time Limits for Denial WAC WAC Whether the claim or request for preauthorization is made in writing or through other claim presentation or preauthorization procedures set out in the contract, any denial because of an experimental or investigational exclusion or limitation, must be done in writing within twenty working days of receipt of a fully documented request. The issuer may extend the review period beyond twenty days only with the informed written consent of the enrollee. Grievance Procedures Definition RCW 48.43.005 (21) WAC (11) WAC means a written complaint submitted by or on behalf of an enrollee regarding service delivery issues other than denial of payment for, or nonprovision of, medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier. 48.43.530(8) Contract must provide a clear explanation of the grievance process.