S-2053

AN ACT Relating to mental health utilization review; and adding a new section to chapter 48.43 RCW.

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

NEW SECTION. Sec. 1. A new section is added to chapter 48.43 RCW to read as follows:

The definitions in subsection (1) of this section apply throughout this section unless the context clearly requires otherwise.

(1)(a) "Health carrier" includes disability insurers regulated under chapter 48.20 or 48.21 RCW, health care service contractors regulated under chapter 48.44 RCW, plans operating under the health care authority under chapter 41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW, health maintenance organizations regulated under chapter 48.46 RCW, and insuring entities regulated under this chapter.

(b) "Mental health practitioners" include only the following: Any generally recognized medical specialty of practitioners licensed under chapter 18.57 or 18.71 RCW who provide mental health services, advanced practice psychiatric nurses as authorized by the nursing care quality assurance commission under chapter 18.79 RCW, psychologists licensed under chapter 18.83 RCW, social workers, marriage and family therapists, and mental health counselors certified under chapter 18.19 RCW.

(c) "Utilization review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of outpatient mental health care services.

(d) "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, or a mental health care practitioner providing services to a covered person can contest an adverse determination given by a health carrier or its designee utilization review organization, which results in the denial, reduction, or termination of a requested outpatient mental health care service.

(2) Every health carrier that provides coverage for any outpatient mental health service shall clearly disclose in any document that describes its covered benefits any mental health services or diagnoses that are excluded from coverage that are listed in the current version of the diagnostic and statistical manual, and a specific description of how the outpatient mental health services are managed.

(3) Utilization review procedures of health carriers that provide coverage for outpatient mental health services must comply with the following:

(a) Persons performing utilization review functions shall be mental health practitioners who shall receive training, in an amount determined by the carrier, to assure knowledge of applicable Washington state laws relevant to treatment of mental disorders, including confidentiality laws, the uniform disciplinary act, and the duty to warn. When an appeal occurs, the person reviewing the appeal for a health carrier shall be a professional peer of the mental health care practitioner who is qualified to provide the mental health service being appealed.

(b) A health carrier's plan for utilization review of mental health services, including criteria used to determine medical necessity, must be filed with the commissioner, and be available upon request.

(c) Any preliminary assessment performed by an agent or employee of the health carrier made during the course of a telephonic or other interview with an enrollee involving preauthorization for the purpose of establishing initial or continuing outpatient mental health benefits or coverage, shall be confirmed or modified in writing by the treating mental health care professional who shall determine the diagnosis.

(d) Persons performing utilization review activities may only have access to those mental health practitioner records that would substantiate the need for additional services for the enrollee for whom utilization review activity is being conducted. However, treatment notes would not be available for review.

(e) Utilization review processes and procedures shall comply with all applicable state and federal laws regarding the confidentiality of mental health records.

(4) A health carrier is responsible for the implementation of this section, whether it performs the utilization review functions itself, or whether it contracts with another entity.