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. Appeals Expedited RCW The issuer must respond as expeditiously as possible to an expedited 48.43.530(5)(c) review request, preferably within twenty-four hours, but in no case Procedures Internal WAC longer than seventy-two hours. The decision regarding an expedited Reviews of (Cont’d) Adverse WAC The issuer's response to an expedited review request may be Benefit delivered orally, and must be reduced to and issued in Determinations writing not later than 72 hours after the date of the decision. under Regardless of who makes the issuer's determination, the time frame for providing a response to an expedited review Fathered Plans request begins when the issuer first receives the request. (Cont’d) WAC If the issuer requires additional information to determine whether the service being reviewed is covered, the issuer must request such information as soon as possible after receiving the request for expedited review. WAC An issuer may require exhaustion of the internal appeal process before appellant may request external review in urgent care situations that justify expedited review. WAC Expedited review must be conducted by appropriate clinician(s) in the same or similar specialty as would typically manage the case being reviewed. The clinician(s) must not have been involved in making the initial adverse determination. 42 U.S.C. Independent An enrollee may seek review by a certified independent review organization §300gg-19(b) Review of appeals of an issuer's decision to deny, modify, reduce, or terminate coverage of or RCW (“IRO”) 48.43.535(2) for both payment for a health care service, after exhausting the issuer's internal
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. Appeals Procedures (Cont’d) Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans (Cont’d) RCW 48.43.530(5)(c) WAC The issuer must respond as expeditiously as possible to an expedited review request, preferably within twenty-four hours, but in no case longer than seventy-two hours. The decision regarding an expedited WAC The issuer's response to an expedited review request may be delivered orally, and must be reduced to and issued in writing not later than 72 hours after the date of the decision. Regardless of who makes the issuer's determination, the time frame for providing a response to an expedited review request begins when the issuer first receives the request. WAC If the issuer requires additional information to determine whether the service being reviewed is covered, the issuer must request such information as soon as possible after receiving the request for expedited review. WAC An issuer may require exhaustion of the internal appeal process before appellant may request external review in urgent care situations that justify expedited review. WAC Expedited review must be conducted by appropriate clinician(s) in the same or similar specialty as would typically manage the case being reviewed. The clinician(s) must not have been involved in making the initial adverse determination. Independent Review of appeals (“IRO”) for both 42 U.S.C. §300gg-19(b) RCW 48.43.535(2) An enrollee may seek review by a certified independent review organization of an issuer's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service, after exhausting the issuer's internal
cl-forms-19-hcsc-sg-analyst-checklist.docx