"NEW SECTION.  Sec. 7   (1) There is a need for a process for the fair consideration of disputes relating to decisions by retainer medicine providers that offer retainer health care practices to deny, modify, reduce, or terminate coverage of or provision of primary care services for a retainer subscriber.
     (2) A retainer subscriber may seek review by a certified independent review organization of a provider's decision to deny, modify, reduce, or terminate coverage of provision of a primary health care service, and receiving a decision that is unfavorable to the retainer subscriber, or after the retainer health care practice has exceeded the timelines for grievances required under this chapter, without good cause and without reaching a decision.
     (3) The commissioner must establish and use a rotational registry system for the assignment of a certified independent review organization to each dispute. The system should be flexible enough to ensure that an independent review organization has the expertise necessary to review the particular medical condition or service at issue in the dispute.
     (4) Retainer health care practices must provide to the appropriate certified independent review organization, not later than the third business day after the date the retainer health care practice receives a request for review, a copy of:
     (a) Any medical records of the retainer subscriber that are relevant to the review;
     (b) Any documents used by the retainer health care practice in making the determination to be reviewed by the certified independent review organization;
     (c) Any documentation and written information submitted to the retainer health care practice in support of the appeal; and
     (d) A list of each provider who has provided care to the retainer subscriber and who may have medical records relevant to the appeal.
     (5) The medical reviewers from a certified independent review organization will make determinations regarding the medical necessity or appropriateness of, and the application of retainer agreement coverage provisions to, primary care services for a retainer subscriber. The medical reviewers' determinations must be based upon their expert medical judgment, after consideration of relevant medical, scientific, and cost-effectiveness evidence, and medical standards of practice in the state of Washington. Except as provided in this subsection, the certified independent review organization must ensure that determinations are consistent with the scope of covered primary care benefits as outlined in the retainer agreement. Medical reviewers may override the provider's medical necessity or appropriateness standards if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.
     (6) Once a request for an independent review determination has been made, the independent review organization must proceed to a final determination, unless requested otherwise by both the provider and the retainer subscriber or the retainer subscriber's representative.
     (7) Retainer health care practices must timely implement the certified independent review organization's determination, and must pay the certified independent review organization's charges.
     (8) When a retainer subscriber requests independent review of a dispute under this section, and the dispute involves a retainer health care practice's decision to modify, reduce, or terminate an otherwise covered primary care service that a retainer subscriber is receiving at the time the request for review is submitted and the retainer health care practice's decision is based upon a finding that the primary care service, or level of primary care service, is no longer medically necessary or appropriate, the retainer health care practice must continue to provide the primary care service if requested by the retainer subscriber until a determination is made under this section. If the determination affirms the retainer health care practice's decision, the enrollee may be responsible for the cost of the continued primary care service.
     (9) A certified independent review organization may notify the commissioner if, based upon its review of disputes under this section, it finds a pattern of substandard or egregious conduct by a retainer health care practice.
     (10) The commissioner shall adopt rules to implement this section."