Prior Transparency RCW If the plan imposes different authorization standards and Authorization of Standards 48.43.016(1) criteria for a covered service among tiers of contracting and Critieria providers of the same licensed profession, the contract must inform enrollees which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers. RCW Plan must post on its web site and provide upon the request of 48.43.016(3) a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. Prohibited RCW Plan may not require prior authorization for an evaluation and Practices 48.43.016(2) management visit or an initial treatment visit with a contracted Prior provider in a new episode of chiropractic, physical therapy, Authorization Prohibited occupational therapy, East Asian medicine, massage therapy, or (Cont’d) Practices speech and hearing therapies. (Cont’d) Plan may require a referral or prescription for these therapies, other than chiropractic. RCW 48.43.515(5) RCW "New episode of care" means treatment for a new or 48.43.016 recurrent condition for which the enrollee has not been (6)(a) treated by the provider within the previous ninety days and is not currently undergoing any active treatment. RCW "Contracting provider" does not include providers 48.43.016 employed within an integrated delivery system operated by (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
Prior Authorization Transparency of Standards and Critieria RCW 48.43.016(1) If the plan imposes different authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession, the contract must inform enrollees which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers. RCW 48.43.016(3) Plan must post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. Prior Authorization (Cont’d) Prohibited Practices Prohibited Practices (Cont’d) RCW 48.43.016(2) Plan may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracted provider in a new episode of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies. 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" means 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. 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 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
checklist-forms-2018-hcsc-individual-analyst-checklist.docx