Drug (Cont’d) Exception Process (Cont’d) Drug WAC Issuer must maintain a documented drug utilization review Utilization and (5) program with written procedures to assure that reviews are Review - conducted in a timely manner. Reequirement WAC Nonurgent review request" any request for approval of care to Maintain (1)(a) or treatment where the request is made in advance of the patient Documented obtaining medical care or services, or a renewal of a previously Program approved request, and is not an urgent care request. WAC "Urgent care review request" means any request for approval of care or treatment where the passage of time could seriously jeopardize the life or health of the patient, seriously jeopardize the patient's ability to regain maximum function or, in the opinion of a provider with knowledge of the patient's medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Drug (5)(A)(i) For urgent care review requests: Utilization WAC Must approve the request within hours if the Review - (5)(a)(i)(A) information provided is sufficient to approve the claim and Requirement include the authorization number, if a prior authorization To Maintain number is required, in its approval; Documented WAC Must deny the request within forty-eight hours if the Program requested service is not medically necessary and the (Cont’d) (5)(a)(i)(B) information provided is sufficient to deny the claim; or
(Cont’d) Drug Exception Process (Cont’d) Drug Utilization Review - WAC and (5) Issuer must maintain a documented drug utilization review program with written procedures to assure that reviews are conducted in a timely manner. Reequirement to Maintain Documented Program WAC (1)(a) Nonurgent review request" any request for approval of care or treatment where the request is made in advance of the patient obtaining medical care or services, or a renewal of a previously approved request, and is not an urgent care request. WAC "Urgent care review request" means any request for approval of care or treatment where the passage of time could seriously jeopardize the life or health of the patient, seriously jeopardize the patient's ability to regain maximum function or, in the opinion of a provider with knowledge of the patient's medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. Drug (5)(A)(i) For urgent care review requests: Utilization Review - Requirement To Maintain WAC (5)(a)(i)(A) Must approve the request within hours if the information provided is sufficient to approve the claim and include the authorization number, if a prior authorization number is required, in its approval; Documented Program (Cont’d) WAC (5)(a)(i)(B) Must deny the request within forty-eight hours if the requested service is not medically necessary and the information provided is sufficient to deny the claim; or