"Adverse benefit determination" has the same meaning as defined in RCW 48.43.005
and WAC 284-43-0160
"Appellant" means an applicant or a person covered as an enrollee, subscriber, policy holder, participant, or beneficiary of an individual or group health plan, and when designated, their representative. Consistent with the requirements of WAC 284-43-2000
, providers seeking expedited review of an adverse benefit determination on behalf of an appellant may act as the appellant's representative even if the appellant has not formally notified the health plan or carrier of the designation.
"External appeal or review" means the request by an appellant for an independent review organization to determine whether the carrier or health plan's internal appeal decisions are correct.
"Internal appeal or review" means an appellant's request for a carrier or health plan to review and reconsider an adverse benefit determination.
[Statutory Authority: RCW 48.02.060
, and 48.43.537
. WSR 16-23-168 (Matter No. R 2016-17), § 284-43-3010, filed 11/23/16, effective 1/1/17. Statutory Authority: RCW 48.02.060
. WSR 16-14-106 (Matter No. R 2016-11), § 284-43-3010, filed 7/6/16, effective 8/6/16. WSR 16-01-081, recodified as § 284-43-3010, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060
, and The Patient Protection and Affordable Care Act, P.L. 111-148, as amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-505, filed 11/7/12, effective 11/20/12.]