medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Plan may require a referral or prescription for these therapies, other than chiropractic. RCW 48.43.515(5) RCW "New episode of care" treatment for a new or recurrent 48.43.016 condition for which the enrollee has not been treated by (6)(a) the provider within the previous ninety days and is not currently undergoing any active treatment. Prior Prohibited RCW "Contracting provider" does not include providers Authorization Practices 48.43.016 employed within an integrated delivery system operated by (Cont’d) (Cont’d) (6)(b) an HCSC. Issuer must RCW Any provider with whom the issuer consults regarding a Consult with 48.43.016(4) decision to deny, limit, or terminate covered services must hold Licensed a license, certification, or registration, in good standing and Provider in must be in the same or related health field as the provider Field Being being reviewed or of a specialty which entails the same or Reviewed similar covered health care service. No Required RCW Issuer may not require a provider to provide a discount from Discounts 48.43.016(5) and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party. Provider RCW Access to Plan must allow enrollee to choose a primary care provider who Requirements 48.43.515(2); PCPs is accepting new enrollees from a list of participating providers. WAC 284-170-360(1)
medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Plan may require a referral or prescription for these therapies, other than chiropractic. RCW 48.43.515(5) RCW 48.43.016 (6)(a) "New episode of care" treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment. Prior Authorization (Cont’d) Prohibited Practices (Cont’d) RCW 48.43.016 (6)(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by an HCSC. Issuer must Consult with Licensed Provider in Field Being Reviewed RCW 48.43.016(4) Any provider with whom the issuer consults regarding a decision to deny, limit, or terminate covered services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the provider being reviewed or of a specialty which entails the same or similar covered health care service. No Required Discounts RCW 48.43.016(5) Issuer may not require a provider to provide a discount from and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party. Provider Requirements Access to PCPs RCW 48.43.515(2); Plan must allow enrollee to choose a primary care provider who is accepting new enrollees from a list of participating providers. WAC 284-170-360(1)
cl-forms-19-hcsc-ind-analyst-checklist.docx