(1) This section applies to health benefit plans as defined in RCW 48.43.005
, contracts for limited health care services as defined in RCW 48.44.035
, and stand-alone dental and stand-alone vision plans. This section applies to plans issued or renewed on or after January 1, 2018.
(2) A carrier or its designated or contracted representative must have an extenuating circumstances policy which eliminates the administrative requirement for a prior authorization of services when an extenuating circumstance prevents a participating provider or facility from obtaining a required prior authorization before a service is delivered.
(3) For purposes of this section, an extenuating circumstance means an unforeseen event or set of circumstances which adversely affects the ability of a participating provider or facility to request prior authorization prior to service delivery.
(4) When a carrier or its designated contracted representative is notified of the occurrence of an extenuating circumstance by a participating provider or facility, either before a claim is submitted or at the initiation of an appeal, the carrier or its designated or contracted representative must process the claim or appeal without any administrative requirement for a prior authorization.
(5) The following situations are extenuating circumstances and must be included in the extenuating circumstances policy:
(a) A participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a prior authorization;
(b) A participating provider or facility is unable to anticipate the need for a prior authorization before or while performing a service; and
(c) An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to delivery of the service.
(6) A carrier or its designated or contracted representative may require a participating provider or facility to follow certain policies and procedures in order for services to qualify as an extenuating circumstance, such as requirements for documentation or a time frame for claims submission. The policies and procedures that participating providers and facilities must follow in order to submit a claim (or initiate an appeal) for a service that qualifies as an extenuating circumstance must be posted online. Claims and appeals related to an extenuating circumstance may still be reviewed for appropriateness, level of care, effectiveness, benefit coverage and medical necessity under the criteria for the applicable plan, based on the information available to the provider or facility at the time of treatment.
(7) Requirements of WAC 284-43-2000
apply to extenuating circumstances.
(8) This section does not apply to prescription drug services.