Provider Requirements (Cont’d) RCW 48.46.280(1) Does the contract provide coverage for reconstructive breast surgery resulting from a Reconstructive mastectomy which resulted from disease, illness, or injury? breast surgery RCW 48.46.280(2) Must provide coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast. WHCRA, 29 USC Must include all stages of reconstructive surgery on the affected breast, prostheses, and §1185b (a) treatment of physical complications of the mastectomy, including lymphedema. Retrospective RCW 48.43.525 (1) Carrier cannot retrospectively deny coverage for emergency and nonemergency care that had prior Denial authorization under the plan’s written policies at the time the care was rendered. Thiringer v. American If the contract includes a subrogation provision, does it: Motors Ins., Make clear that the issuer is entitled only to excess after the enrollee is fully compensated Subrogation 91 WN 2d 215, 588 Inform enrollee that legal expenses will be apportioned equitably, whether or not recovery is made P.2d 191 (1978) Have any provision which would inappropriately require full reimbursement for all medical expenses. The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not
Provider Requirements (Cont’d) Reconstructive breast surgery RCW 48.46.280(1) RCW 48.46.280(2) WHCRA, 29 USC §1185b (a) Does the contract provide coverage for reconstructive breast surgery resulting from a mastectomy which resulted from disease, illness, or injury? Must provide coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it equal in size with the diseased breast after definitive reconstructive surgery on the diseased breast. Must include all stages of reconstructive surgery on the affected breast, prostheses, and treatment of physical complications of the mastectomy, including lymphedema. Retrospective Denial RCW 48.43.525 (1) Carrier cannot retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan’s written policies at the time the care was rendered. Subrogation Thiringer v. American Motors Ins., 91 WN 2d 215, 588 P.2d 191 (1978) If the contract includes a subrogation provision, does it: Make clear that the issuer is entitled only to excess after the enrollee is fully compensated Inform enrollee that legal expenses will be apportioned equitably, whether or not recovery is made Have any provision which would inappropriately require full reimbursement for all medical expenses. The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not
checklist-forms-hmo-large-group.docx