WSR 08-01-025

PERMANENT RULES

OFFICE OF

INSURANCE COMMISSIONER

[ Insurance Commissioner Matter No. R 2005-04 -- Filed December 10, 2007, 9:03 a.m. , effective January 10, 2008 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: WAC 284-43-260 requires health carriers to permit a contracted network provider to select another provider who will serve as a substitute in the absence of the contracted provider. This is commonly referred to as a "locum tenens" provision. The rule sets standards for providers who act as substitutes, permits carriers to require the use of separate billing codes, and exempts medicare advantage plans from the rule.

WAC 284-43-262 requires carriers to permit network providers who are called to active military service to seek reinstatement within one hundred twenty days after returning to civilian life upon a showing that the provider meets the carrier's then-current credentialing standards, even if the carrier's network is otherwise closed or full.

Statutory Authority for Adoption: RCW 48.02.060 and 48.43.515.

Adopted under notice filed as WSR 07-17-165 on August 22, 2007.

Changes Other than Editing from Proposed to Adopted Version: 1. WAC 284-43-260 introductory paragraphs: Added intent paragraph regarding the importance [of] patient safety and quality of care.

2. WAC 284-43-260 (1)(e): Added requirement that a substitute provider must have a current drug enforcement agency certificate, if applicable.

3. WAC 284-43-260(3): Added a provision allowing the carrier to require the contracted provider to use the "Q6 modifier" when billing for services provided by the substitute provider. (The Q6 modifier is a commonly used billing code that alerts a carrier that a substitute provider supplied the billed services.)

4. WAC 284-43-260(4): Clarified that nothing in the rule is intended to prevent the carrier from requiring the substitute provider to accept the carrier's fee schedule or accept the carrier's usual and customary charge as payment in full. (This should prevent the substitute provider from balance billing the patient.)

5. WAC 284-43-260(5): Added an exception for medicare advantage or other health plans administered by the federal government that require precredentialing of all participating providers.

A final cost-benefit analysis is available by contacting Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, phone (360) 725-7041, fax (360) 586-3109, e-mail KacyS@oic.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 2, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

Date Adopted: December 10, 2007.

Mike Kreidler

Insurance Commissioner

OTS-9368.11


NEW SECTION
WAC 284-43-260   Standards for temporary substitution of contracted network providers -- "Locum tenens" providers.   It is a longstanding and widespread practice for contracted network providers to retain substitute providers to take over their professional practices when the contracted network providers are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for contracted network providers to bill and receive payment for the substitute providers' services as though they were provided by the contracted network provider. The contracted network provider generally pays the substitute provider based on an agreement between the contracted network provider and the substitute provider, and the substitute provider has the status of an independent contractor rather than an employee of the contracted network provider. These substitute providers are commonly called "locum tenens" providers.

In order to protect patients and ensure that they benefit from seamless quality care when contractual network providers are away from their practices, and that patients receive quality care from qualified substitute providers, carriers may require substitute providers to provide the information required in subsection (1) of this section.

The following are minimum standards for temporary provider substitution and do not prevent a carrier from entering into other agreed arrangements with its contracted network providers for terms that are less restrictive or more favorable to providers.

Carriers must permit the following categories of contracted network provider to arrange for temporary substitution by a substitute provider: Doctor of medicine, doctor of osteopathic medicine, doctor of dental surgery or dental medicine, doctor of chiropractic, podiatric physician and surgeon, doctor of optometry, doctor of naturopathic medicine and advanced registered nurse practitioner.

(1) At the time of substitution, the substitute provider:

(a) Must have a current Washington license and be legally authorized to practice in this state;

(b) Must provide services under the same scope of practice as the contracted network provider;

(c) Must not be suspended or excluded from any state or federal health care program;

(d) Must have professional liability insurance coverage; and

(e) Must have a current drug enforcement certificate, if applicable.

(2)(a) Carriers must allow a contracted network provider to arrange for a substitute provider for at least sixty days during any calendar year.

(b) A carrier must grant an extension if a contracted network provider demonstrates that exceptional circumstances require additional time away from his or her practice.

(3) A carrier may require that the contracted network provider agree to bill for services rendered by the substitute provider using the carrier's billing guidelines, including use of HIPAA compliant code sets, commonly known as the Q-6 modifier, or any other code or modifier that the Centers for Medicare and Medicaid Services (CMS) adopts in the future.

(4) Nothing in this section is intended to prevent the carrier from requiring:

(a) That the contracted network provider require acceptance by the substitute provider of the carrier's fee schedule; or

(b) Acceptance by the substitute provider of the carrier's usual and customary charge as payment in full.

(5) This rule does not apply to Medicare Advantage or other health plans administered by the federal government that require precredentialing of all providers.

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NEW SECTION
WAC 284-43-262   Rule concerning contracted network providers called to active duty military service.   In lieu of substitution of a provider during a period of active duty military service longer than sixty continuous days, carriers must provide contracted network providers with the opportunity to return to the carrier's network after the provider's active duty military service is completed.

(1)(a) A carrier must allow the provider a period of at least one hundred twenty days to request a return to contracted network provider status after the provider returns to civilian status.

(b) The one hundred twenty-day period must begin no earlier than the date the provider's period of active duty ends.

(2)(a) As a condition for return to the carrier's network, the carrier may require that the provider provide evidence that he or she meets the carrier's then-current standards for credentialing.

(b) If the provider meets or exceeds the credentialing standards of the carrier and timely requests a return to contracted network provider status, the carrier must grant the request whether or not the carrier's network is otherwise closed.

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Washington State Code Reviser's Office