WAC Whether the claim or request for preauthorization is made in writing or through other claim presentation or preauthorization procedures set out WAC in the contract, any denial because of an experimental or investigational (1) 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. Experimental Requirements or (Cont’d) Investigational Treatment (Cont’d) Grievance RCW 48.43.005 "Grievance" means a written complaint submitted by or on behalf of an Procedures (21) enrollee regarding service delivery issues other than denial of payment WAC for, or nonprovision of, medical services, including dissatisfaction with (11) medical care, waiting time for medical services, provider or staff attitude WAC or demeanor, or dissatisfaction with service provided by the health carrier. RCW Contract must provide a clear explanation of the grievance process. 48.43.530(8) Process must be accessible to enrollees who are limited English RCW speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance. 48.43.530(9)
Experimental or Investigational Treatment (Cont’d) Requirements (Cont’d) WAC WAC (1) 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 RCW 48.43.005 (21) WAC (11) WAC "Grievance" 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. RCW 48.43.530(8) Contract must provide a clear explanation of the grievance process. Process must be accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance. RCW 48.43.530(9)
cl-forms-19-hmo-ind-analyst-checklist.docx