45 CFR The carrier satisfies its obligations to provide contraceptive coverage §147.131 if it reasonably and in good faith relies on a by the (e)(1) employer that it is eligible for this accommodation and the carrier complies with these obligations. Application to 45 CFR The requirements apply to student health insurance coverage Student Health §147.131 arranged by an eligible organization that is an institution of Coverage (f) higher education. Requirements of WAC Contract must specifically explain issuer's medical necessity Medical Necessity Medical determination process. Necessity WAC Process must: Determination be conducted fairly, and with transparency to enrollees and Process providers, at a minimum when an enrollee or their representative appeals or seeks review of an adverse benefit determination; WAC Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient; Medical Requirements of WAC Identify the information needed in the decision-making process Necessity Medical and incorporate appropriate outcomes within a developmental (Cont’d) Necessity framework; Determination WAC Ensure that when the interpretation of the medical purpose of Process interventions is part of the medical necessity decision making, the (Cont’d) 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;
45 CFR §147.131 (e)(1) The carrier satisfies its obligations to provide contraceptive coverage if it reasonably and in good faith relies on a by the employer that it is eligible for this accommodation and the carrier complies with these obligations. Application to Student Health Coverage 45 CFR §147.131 (f) The requirements apply to student health insurance coverage arranged by an eligible organization that is an institution of higher education. Medical Necessity Requirements of Medical WAC Contract must specifically explain issuer's medical necessity determination process. Necessity Determination Process WAC Process must: be conducted fairly, and with transparency to enrollees and providers, at a minimum when an enrollee or their representative appeals or seeks review of an adverse benefit determination; WAC Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient; Medical Necessity (Cont’d) Requirements of Medical Necessity WAC Identify the information needed in the decision-making process and incorporate appropriate outcomes within a developmental framework; Determination Process (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;
checklist-forms-2018-disability-sg-analyst-checklist.docx