The issuer furnishes the appellant or their representative with a paper version of the electronically furnished documents if requested. Expedited RCW The Issuer must provide an expedited review process at any in the Internal 48.43.530(5)(c) review process IF: Reviews of WAC Adverse Benefit WAC The appellant is currently receiving or is prescribed treatment or benefits that would end due to the adverse benefit determination; under OR WAC The ordering provider or the issuer's medical director reasonably Fathered Plans determines that following the normal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or would subject the appellant to severe and intolerable pain; OR Appeals Expedited WAC The determination is related to an issue related to admission, Internal Procedures availability of care, continued stay, or emergency health care Reviews of (Cont’d) services where the appellant has not been discharged from the Adverse emergency room or transport service. Benefit WAC If the treating health care provider determines that a delay could jeopardize the enrollee's health or ability to regain maximum function, the issuer must presume the need for expedited review, and treat the review request as under Non- such, including the need for an expedited determination of an external review under RCW 48.43.535. Fathered WAC Appellant is not entitled to expedited review if the treatment has already (Cont’d) been delivered and the review involves payment for the delivered treatment, if the situation is not urgent, or if the situation does not involve the delivery of services for an existing condition, illness, or disease. WAC An expedited review may be filed by an appellant, the appellant's authorized representative, or the appellant's provider orally, or in writing.
The issuer furnishes the appellant or their representative with a paper version of the electronically furnished documents if requested. Expedited Internal Reviews of Adverse RCW 48.43.530(5)(c) WAC The Issuer must provide an expedited review process at any in the review process IF: Benefit under WAC The appellant is currently receiving or is prescribed treatment or benefits that would end due to the adverse benefit determination; OR Fathered Plans WAC The ordering provider or the issuer's medical director reasonably determines that following the normal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or would subject the appellant to severe and intolerable pain; OR Appeals Procedures (Cont’d) Expedited Internal Reviews of Adverse WAC The determination is related to an issue related to admission, availability of care, continued stay, or emergency health care services where the appellant has not been discharged from the emergency room or transport service. Benefit under Non- WAC If the treating health care provider determines that a delay could jeopardize the enrollee's health or ability to regain maximum function, the issuer must presume the need for expedited review, and treat the review request as such, including the need for an expedited determination of an external review under RCW 48.43.535. Fathered (Cont’d) WAC Appellant is not entitled to expedited review if the treatment has already been delivered and the review involves payment for the delivered treatment, if the situation is not urgent, or if the situation does not involve the delivery of services for an existing condition, illness, or disease. WAC An expedited review may be filed by an appellant, the appellant's authorized representative, or the appellant's provider orally, or in writing.
cl-forms-19-hmo-ind-analyst-checklist.docx