This section sets the maximum fee schedule for independent reviews, and the process of review and determination of a case referred to an independent review organization (IRO).
(1) IROs may not charge more than the following amount for each review:
Category | Amount |
Contract review, interpretation of health plan coverage provisions | $600 | |
Standard medical review, straightforward review of medical necessity or adverse determination | $700 | |
Highly specialized medical review of complex conditions or experimental or investigational treatment | $1000 | |
Medical review with multiple reviewers | $1100 | |
Surcharge for expedited review | $200 | |
The fees in this section include all costs for time and materials associated with the review including, but not limited to:
(a) Record transmission expenses such as postage and facsimile costs; and
(b) Medical record handling and duplication.
(2) If the IRO and the health care plan agree in advance that the referral includes both a contract review and a medical review, the IRO may charge both fees.
(3) If an IRO charges more than the maximum fees allowed under this section, the commissioner may take action as described in WAC
284-43A-120.
[Statutory Authority: RCW
48.02.060,
48.43.535, and
48.43.537. WSR 16-23-168 (Matter No. R 2016-17), § 284-43A-130, filed 11/23/16, effective 1/1/17.]