Services (EHB) (Cont’d) Benefit WAC Plan must include the following benefit requirements Requirements classified to the ambulatory patient services category: Classified to Chiropractic care; Ambulatory RCW TMJ disorder treatment (WAC 284-43-5642(1)(d)(ii)); and Services 48.44.315 Category WAC Diabetes-related care and supplies (RCW , , and ). Internal appeals / 42 U.S.C. Does the plan have a fully operational, comprehensive process for Appeals review of adverse §300gg-19 (a) review of appeals / adverse benefit determinations? Procedures benefit decisions 45 C.F.R. under Both §147.136(b) Resources: ; Grand-fathered RCW 48.43.530(1) and Non-Grand- WAC fathered plans WAC The issuer’s process for review of adverse benefit determinations must meet accepted national certification standards such as used by the National Committee for Quality Assurance, except as otherwise required under Chapter 284-43 WAC. RCW 48.43.530 (8) Does the contract provide a clear explanation of the WAC 284-43-3050 appeal / review of adverse benefit determination process? WAC 284-43-4020(2)(a) Appeals Internal appeals RCW 48.43.530(9) The process must be accessible to enrollees who are / review of WAC Procedures limited English speakers, who have literacy problems, or adverse benefit (Cont’d) who have physical or mental disabilities that impede decisions under WAC Both Grand-
Services (EHB) (Cont’d) Benefit Requirements Classified to WAC Plan must include the following benefit requirements classified to the ambulatory patient services category: Chiropractic care; Ambulatory Services RCW 48.44.315 TMJ disorder treatment (WAC 284-43-5642(1)(d)(ii)); and Category WAC Diabetes-related care and supplies (RCW , , and ). Appeals Procedures Resources: ; Internal appeals / review of adverse benefit decisions under Both Grand-fathered and plans 42 U.S.C. §300gg-19 (a) 45 C.F.R. §147.136(b) RCW 48.43.530(1) WAC Does the plan have a fully operational, comprehensive process for review of appeals / adverse benefit determinations? WAC The issuer’s process for review of adverse benefit determinations must meet accepted national certification standards such as used by the National Committee for Quality Assurance, except as otherwise required under Chapter 284-43 WAC. RCW 48.43.530 (8) WAC 284-43-3050 WAC 284-43-4020(2)(a) Does the contract provide a clear explanation of the appeal / review of adverse benefit determination process? Appeals Procedures (Cont’d) Internal appeals / review of adverse benefit decisions under Both Grand- RCW 48.43.530(9) WAC WAC The process must be accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede fathered Non-Grand-
cl-forms-19-hcsc-ind-analyst-checklist.docx