H-0505

AN ACT Relating to utilization review of health care benefits; adding new sections to chapter 48.42 RCW; and providing an effective date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. A new section is added to chapter 48.42 RCW to read as follows:

The definitions set forth in this section apply in section 2 of this act.

(1) "Review agent" means a person who performs utilization review for a disability insurer, health care service contractor, or health maintenance organization.

(2) "Utilization review" means a system for reviewing the appropriate and efficient use or proposed use of health care services by insureds, subscribers, enrollees, or other beneficiaries of disability insurance policies, health care contracts, or health maintenance agreements for the purpose of approving, denying, or otherwise making recommendations concerning payment or coverage for health care services.

(3) "Utilization review plan" means a description of the criteria, procedures, and standards governing utilization review activities performed by a review agent.

NEW SECTION. Sec. 2. A new section is added to chapter 48.42 RCW to read as follows:

Each review agent shall develop a utilization review plan. The disability insurer, health care service contractor, or health maintenance organization shall file the plan with the insurance commissioner. The plan must include the following:

(1) Specific standards, criteria, and procedures to be used in evaluating hospital, inpatient, or outpatient care that has been proposed or is being or has been delivered;

(2) Those circumstances under which utilization review may be delegated to a hospital utilization review program;

(3) The provisions by which patients or providers may seek reconsideration or appeal of adverse decisions by the review agent and the time period in which the agent must respond to the request for reconsideration or appeal;

(4) The number, type, and qualifications of the personnel employed by or contracting with the disability insurer, health care service contractor, or health maintenance organization to perform the utilization review;

(5) The procedures and policies to ensure that a representative of the review agent is reasonably accessible at least five days a week during normal business hours;

(6) The procedures and policies to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

(7) A copy of the written material intended to be sent to the insureds, subscribers, enrollees, or beneficiaries and health care providers to inform them of the requirements of the utilization review plan;

(8) A copy of any payment incentive provision or plan designed to control the amount, duration, or setting in which health care services are rendered;

(9) Evidence of liability insurance carried by the review agent or the insurer, contractor, or organization to cover potential liability arising from utilization review activities. This liability insurance coverage shall be in an amount, type, and nature satisfactory to the insurance commissioner; and

(10) Other information the insurance commissioner determines to be appropriate.

No insurer, health care service contractor, or health maintenance organization may conduct a utilization review until a plan has been filed with and approved by the commissioner.

The insurance commissioner may disallow any utilization review plan if it does not meet the standards for utilization review adopted by the commissioner by rule.

NEW SECTION. Sec. 3. This act shall take effect January 1, 1992, but the insurance commissioner may take all actions necessary to ensure that this act is implemented on that date.