WSR 05-20-103



[ Filed October 5, 2005, 10:07 a.m. ]

Original Notice.

Exempt from preproposal statement of inquiry under RCW 34.05.310(4).

Title of Rule and Other Identifying Information: WAC 246-305-990 Maximum fee schedule for independent review organizations certified in Washington.

Hearing Location(s): Room 152, 310 Israel Road S.E., Tumwater, WA 98501, on November 10, 2005, at 9:00 a.m.

Date of Intended Adoption: November 11, 2005.

Submit Written Comments to: Pamela Lovinger, P.O. Box 47850, Olympia, WA 98504-7850, e-mail, fax (360) 236-4626, by November 10, 2005.

Assistance for Persons with Disabilities: Contact Sherry Thomas by November 1, 2005, TTY 711 or (360) 236-4612.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: 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.

Reasons Supporting Proposal: This proposal sets fees that compensate independent review organizations for the reviews they complete. Insurance plans are protected from excessive charges by independent review organizations.

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

Statute Being Implemented: RCW 43.70.235.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of Health, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: P. Lovinger, 310 Israel Road, Olympia, WA, (360) 236-4621.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The requirements for a small business economic impact statement do not apply to rules described under RCW 19.85.025(3) because they adopt fees according to legislative standards.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to rules that set or adjust fees or rates pursuant to legislative standards.

September 30, 2005

Mary C. Selecky



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 $500
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 referral includes 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.


Washington State Code Reviser's Office