Purpose: The proposal sets a maximum fee schedule to implement HB 1140, chapter 54, Laws of 2005. The department is required to create and adopt a maximum fee schedule to cap the amount independent review organizations can charge health plans for conducting independent reviews.

     Statutory Authority for Adoption: Chapter 54, Laws of 2005.

      Adopted under notice filed as WSR 05-20-103 on October 5, 2005.

     Changes Other than Editing from Proposed to Adopted Version: The fee for a contract review increased from $500 to $600. Public comment indicated that attorneys may charge up to $225 an hour and contract reviews typically take two hours. A $500 fee would not allow the independent review organization to cover administrative costs and make a reasonable profit.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 0.

     Date Adopted: November 15, 2005.

Mary C. Selecky

Secretary

OTS-8297.4

NEW SECTION
WAC 246-305-990   Maximum fee schedule.   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 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 department may take action described in WAC 246-305-110.

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