Coverage of RCW 48.21.140 Benefits must not be denied for any eye care service rendered by an Optometry optometrist licensed Chapter RCW, if the service was within the lawful scope of their license, and the contract would have provided the benefits if rendered by a physician licensed under Chapter RCW. Experimental Definition WAC If the contract includes exclusion, reduction or limitation for or Required services that are experimental or investigational, contract must Investigational include a definition of Experimental and Investigational services. WAC The definition must include an identification of the authority or Treatment authorities will make a determination of which services will be considered to be experimental or investigational. Contract Must WAC If the disability insurer or an affiliated entity is the authority State Criteria for making the determination, it must state the criteria it will utilize to Determination make the determination. This requirement may be satisfied by using one or more of the following statements, or other similar statements: Experimental / Contract Must WAC "In determining whether services are experimental or Investigational Criteria for investigational, the plan will consider whether the services are in Treatment Determination general use in the medical community in the state of (Cont’d) (Cont’d) 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 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."
Coverage of Optometry RCW 48.21.140 Benefits must not be denied for any eye care service rendered by an optometrist licensed Chapter RCW, if the service was within the lawful scope of their license, and the contract would have provided the benefits if rendered by a physician licensed under Chapter RCW. Experimental or Investigational Definition Required WAC If the contract includes exclusion, reduction or limitation for services that are experimental or investigational, contract must include a definition of Experimental and Investigational services. Treatment WAC The definition must include an identification of the authority or authorities will make a determination of which services will be considered to be experimental or investigational. Contract Must State Criteria for Determination WAC If the disability insurer or an affiliated entity is the authority making the determination, it must state the criteria it will utilize to make the determination. This requirement may be satisfied by using one or more of the following statements, or other similar statements: Experimental / Investigational Treatment (Cont’d) Contract Must Criteria for Determination (Cont’d) WAC "In determining whether services are experimental or investigational, the plan will consider whether the services are in general use in the medical community in the state of 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 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."
checklist-forms-2018-disability-sg-analyst-checklist.docx