RCW The issuer may not require that an enrollee file a complaint or Appeals 48.43.530(4)(c) grievance to seeking an appeal or review of an adverse Procedures benefit determination. (Cont’d) Internal WAC Does the contract notify the enrollee that, when the enrollee requests Appeals under reconsideration of a decision to modify, reduce, or terminate an otherwise covered health service that the enrollee is receiving through the health plan, based upon a finding that the health service, or level of Health Plan health service, is no longer medically necessary or appropriate, the issuer must continue to provide that health service until the appeal / review of adverse benefit determination is resolved? RCW The issuer must assist the enrollee with the appeal process. 48.43.530(5)(b) WAC WAC RCW The issuer must cooperate with any representative authorized in writing 48.43.530(5)(d) by the enrollee. WAC RCW The issuer must consider all information submitted by the enrollee or 48.43.530(5)(e) representative. WAC WAC RCW The issuer must investigate and resolve all appeals / requests for review 48.43.530(5)(f) of adverse benefit determination. WAC RCW The review of a decision to deny, modify, reduce, or terminate 48.43.530(4)(a) payment, coverage, authorization, or provision of health care services
Appeals Procedures (Cont’d) RCW 48.43.530(4)(c) The issuer may not require that an enrollee file a complaint or grievance to seeking an appeal or review of an adverse benefit determination. Internal Appeals under Health Plan WAC Does the contract notify the enrollee that, when the enrollee requests reconsideration of a decision to modify, reduce, or terminate an otherwise covered health service that the enrollee is receiving through the health plan, based upon a finding that the health service, or level of health service, is no longer medically necessary or appropriate, the issuer must continue to provide that health service until the appeal / review of adverse benefit determination is resolved? RCW 48.43.530(5)(b) WAC WAC The issuer must assist the enrollee with the appeal process. RCW 48.43.530(5)(d) WAC The issuer must cooperate with any representative authorized in writing by the enrollee. RCW 48.43.530(5)(e) WAC WAC The issuer must consider all information submitted by the enrollee or representative. RCW 48.43.530(5)(f) WAC The issuer must investigate and resolve all appeals / requests for review of adverse benefit determination. RCW 48.43.530(4)(a) The review of a decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services
cl-forms-19-hmo-sg-analyst-checklist.docx