45 CFR §147.131 The issuer satisfies its obligations to provide contraceptive coverage (d)(1)(B) if it reasonably and in good relies on a by the employer that it is eligible for this accommodation and the issuer complies with these obligations. Medical Requirements WAC Contract must specifically explain issuer's medical necessity Necessity of Medical determination process. Necessity WAC Process must: be conducted fairly, and with transparency to enrollees and Process providers, at a minimum when an enrollee or representative appeals or seeks review of an adverse benefit determination; Requirements WAC Include consideration of services that are a logical next step in Medical Necessity of Medical reasonable care if they are appropriate for the patient; (Cont’d) Necessity WAC Identify the information needed in the decision-making process Determination and incorporate appropriate outcomes within a developmental Process framework; (Cont’d) WAC Ensure that when the interpretation of the medical purpose of interventions is part of the medical necessity decision making, the interpretation standard can be explained in writing to an enrollee and providers, and is broad enough to address any of the services encompassed in the ten essential health benefits categories of care; WAC Comply with inclusion of the ten essential health benefits categories; WAC Not discriminate based on age, present or predicted disability, expected length of life, degree of medical dependency, quality of life or other health conditions, race, gender, national origin, sexual orientation and gender identity;
45 CFR §147.131 (d)(1)(B) The issuer satisfies its obligations to provide contraceptive coverage if it reasonably and in good relies on a by the employer that it is eligible for this accommodation and the issuer complies with these obligations. Medical Necessity Requirements of Medical WAC Contract must specifically explain issuer's medical necessity determination process. Necessity Process WAC Process must: be conducted fairly, and with transparency to enrollees and providers, at a minimum when an enrollee or representative appeals or seeks review of an adverse benefit determination; Medical Necessity Requirements of Medical WAC Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient; (Cont’d) Necessity Determination Process WAC Identify the information needed in the decision-making process and incorporate appropriate outcomes within a developmental framework; (Cont’d) WAC Ensure that when the interpretation of the medical purpose of interventions is part of the medical necessity decision making, the interpretation standard can be explained in writing to an enrollee and providers, and is broad enough to address any of the services encompassed in the ten essential health benefits categories of care; WAC Comply with inclusion of the ten essential health benefits categories; WAC Not discriminate based on age, present or predicted disability, expected length of life, degree of medical dependency, quality of life or other health conditions, race, gender, national origin, sexual orientation and gender identity;
cl-forms-19-hmo-sg-analyst-checklist.docx