Expedited WAC The Issuer must provide an expedited review process at any point in Internal the review process IF: Reviews of WAC The appellant is currently receiving or is prescribed treatment Adverse or benefits that end due to the adverse benefit Benefit determination; OR Determinations WAC the ordering provider or the issuer's medical director under reasonably determines that following the normal process response timelines could seriously jeopardize the enrollee's Fathered Plans life, health, or ability to regain maximum function, or would subject the appellant to severe and intolerable pain; OR 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. Expedited WAC If the treating health care provider determines that a trial could Appeal Internal jeopardize the enrollee's health or ability to regain maximum Procedures Reviews of function, the issuer must presume the need for expedited (Cont’d) Adverse review, and treat the review request as such, including the Benefit need for an expedited determination of an external review Determinations under RCW 48.43.535. under WAC Appellant is not entitled to expedited review if the treatment has already been delivered and the review involves payment Fathered Plans for the delivered treatment, if the situation is not urgent, or if (Cont’d) 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.
Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans WAC The Issuer must provide an expedited review process at any point in the review process IF: WAC The appellant is currently receiving or is prescribed treatment or benefits that end due to the adverse benefit determination; OR 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 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. Appeal Procedures (Cont’d) Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans (Cont’d) WAC If the treating health care provider determines that a 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. 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. trial
cl-forms-19-disability-sg-analyst-checklist.docx