BP BHEAD INT H

AN ACT Relating to utilization review activities; adding new sections to chapter 48.44 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. It is the intent of sections 2 and 3 of this act to define standards for utilization review of health care services and to promote the delivery of health care in a cost-effective manner, as well as to encourage the availability of effective and consistent utilization review throughout this state.

NEW SECTION. Sec. 2. Unless the context clearly requires otherwise, the definitions in this section apply throughout section 3 of this act.

(1) "Appeal" means a formal request, either orally or in writing, to reconsider a determination not to certify an admission, extension of stay, or other health care service.

(2) "Adverse determination" means a decision by a review organization not to certify an admission, service, procedure, or extension of stay.

(3) "Certification" means a determination by a utilization review organization that an admission, extension of stay, or other health care service has been reviewed and, based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan.

(4) "Review organization" means a person or entity performing utilization review that is either employed by, affiliated with, under contract with, or acting on behalf of:

(a) A business entity doing business in this state; or

(b) A party that provides or administers health care benefits to citizens of this state, including a disability insurer, a health care service contractor, a health maintenance organization authorized to offer health insurance policies or contracts or pay for the delivery of health care services or treatment in this state, or a designee of one of these parties.

(5) "Utilization review" means the prospective, concurrent, or retrospective assessment of the necessity and appropriateness of the allocation of health care resources and services of a provider or facility, given or proposed to be given to a patient or group of patients. Utilization review does not mean elective requests for clarification of coverage or medical claims review.

NEW SECTION. Sec. 3. (1) Beginning July 1, 1996, every review organization that proposes to provide coverage of inpatient hospital and medical benefits and outpatient surgical benefits for residents of this state with utilization review of those benefits must meet the following standards:

(a) Review organizations must comply with all applicable state and federal laws to protect confidentiality of enrollee medical records;

(b) Notification of a determination to certify by the review organization must be mailed or otherwise communicated either to the provider of record or the enrollee, or both the provider of record and the enrollee, or other appropriate individual, within two business days of the determination, which is based on the receipt of all information necessary to complete the review;

(c) Review organizations must maintain a written description of the appeal procedure by which enrollees or the provider of record may seek review of determinations by the review organization. The appeal procedure must provide for the following:

(i) On appeal, all determinations to deny an admission, service, or procedure as being necessary or appropriate must be made by an individual in a licensed physician category who is familiar with the treatment of the medical condition, procedure, or treatment under discussion and is reasonably available as appropriate to review the case, other than the physician or licensed medical professional who made the initial determination;

(ii) Review organizations must complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty days from the date the appeal is filed and all information necessary to complete the appeal is received; and

(iii) Review organizations must also provide for an expedited appeals process for emergency or life-threatening situations. Review organizations must complete the adjudication of the expedited appeals within two business days of the date the appeal is filed, and the receipt of all information necessary to complete the appeal;

(d) Review organizations must make staff available by toll-free telephone, at least forty hours per week during normal business hours;

(e) Review organizations must have a phone system capable of either accepting or recording, or both accepting and recording, incoming phone calls during other than normal business hours, and must respond to these calls within two business days; and

(f) Review organizations must allow a minimum of forty-eight hours following an emergency admission, service, or procedure for an enrollee or his or her representative to notify the review organization and request certification or continuing treatment for that condition. A review organization must permit immediate hospitalization of an enrollee for whom the physician of record determines the admission to be of a life-threatening emergency, so long as medical necessity is promptly documented. Nothing in this section requires the review organization or another party to authorize payment for services provided during that forty-eight hour period, regardless of medical necessity, if those services do not otherwise constitute covered benefits.

(2) A determination to deny a review organization to the necessity or appropriateness of an admission, service, or procedure must be reviewed by a physician or a licensed medical professional making a determination in accordance with standards or guidelines approved by a physician. A determination not to certify an admission, service, or procedure must be made by a licensed physician.

(3) A notification of a determination not to certify an admission, service, or procedure must include:

(a) The principal reason for the determination; and

(b) The procedures to initiate an appeal of the determination.

(4) Hospitals and physicians must cooperate with the reasonable efforts of review organizations to ensure that all necessary patient information is available in a timely fashion by phone during normal business hours. Procedures must be established by hospitals and physicians to allow on-site review of medical records by review organizations.

(5) A review organization that has received accreditation by a nationally recognized accreditation organization or an organization accredited by the department of health for the purposes of chapter . . ., Laws of 1996 (this act).

NEW SECTION. Sec. 4. Sections 2 and 3 of this act are each added to chapter 48.44 RCW.