and RCW Enrollee may also seek review by a certified independent review 48.43.535(2) organization the carrier has exceeded the timelines provided in WAC plans RCW 48.43.530, without good cause and without reaching a decision. WAC Issuers must use the rotational registry system of certified independent review organizations (IROs) established by OIC, and may not make an assignment to an IRO out of sequence for any reason other than the existence of a conflict of interest, as set forth in WAC Issuers must make available to the enrollee and to any provider acting on behalf of the enrollee all materials provided to the IRO. Independent WAC Issuers must provide IROs with all relevant clinical review criteria Appeals Review of Procedures used by the issuer and relevant medical, scientific, and appeals (Cont’d) effectiveness evidence, the attending or ordering provider's (“IRO”) for recommendations, and a copy of the terms and conditions of both coverage under the relevant health plan. and RCW Enrollees must have at least five business days to submit to the 48.43.535(5) independent review organization in writing additional information that the plans independent review organization must consider when conducting the (Cont’d) external review. RCW An enrollee or carrier may request an expedited external review if the 48.43.535(7)(a) issuer’s decision to deny, modify, reduce, or terminate coverage or payment for a health care service: concerns an admission, availability of care, continued stay, or health care service for which the claimant received emergency services but has not been discharged from a facility; or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the
and plans RCW 48.43.535(2) WAC Enrollee may also seek review by a certified independent review organization the carrier has exceeded the timelines provided in RCW 48.43.530, without good cause and without reaching a decision. WAC Issuers must use the rotational registry system of certified independent review organizations (IROs) established by OIC, and may not make an assignment to an IRO out of sequence for any reason other than the existence of a conflict of interest, as set forth in WAC Issuers must make available to the enrollee and to any provider acting on behalf of the enrollee all materials provided to the IRO. Appeals Procedures (Cont’d) Independent Review of appeals (“IRO”) for both and WAC Issuers must provide IROs with all relevant clinical review criteria used by the issuer and relevant medical, scientific, and evidence, the attending or ordering provider's recommendations, and a copy of the terms and conditions of coverage under the relevant health plan. plans (Cont’d) RCW 48.43.535(5) Enrollees must have at least five business days to submit to the independent review organization in writing additional information that the independent review organization must consider when conducting the external review. RCW 48.43.535(7)(a) An enrollee or carrier may request an expedited external review if the issuer’s decision to deny, modify, reduce, or terminate coverage or payment for a health care service: concerns an admission, availability of care, continued stay, or health care service for which the claimant received emergency services but has not been discharged from a facility; or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the effectiveness
cl-forms-19-hmo-ind-analyst-checklist.docx