WSR 10-13-143




[ Insurance Commissioner Matter No. R 2009-19 -- Filed June 23, 2010, 7:02 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 09-23-062.

Title of Rule and Other Identifying Information: Utilization review of medical services.

Hearing Location(s): OIC Tumwater Office, Training Room 120, 5000 Capitol Boulevard, Tumwater, WA,, on July 27, 2010, at 10:00 a.m.

Date of Intended Adoption: August 9, 2010.

Submit Written Comments to: Kacy Scott, P.O. Box 40258, Olympia, WA 98504-0258, e-mail, fax (360) 586-3106, by July 26, 2010.

Assistance for Persons with Disabilities: Contact Lorie Villaflores by July 26, 2010, TTY (360) 586-0241 or (360) 725-7087.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: WAC 284-43-410 was originally adopted in 2001. RCW 48.165.050 was enacted in 2009 and requires the development of guidelines to require payers (health carriers) to use common and consistent time frames when responding to provider requests for preauthorization of medical services. The statute also directs that the time frames, when possible, shall be consistent with those established by leading national organizations and be based upon the acuity of the patient's need for care or treatment. The proposed rule amends WAC 284-43-410 to comply with the directions of RCW 48.165.050. The rule change will promote more standardization of the terminology and time frames used for health carrier preauthorization processes and will reduce the administrative burden of the preauthorization processes on health care providers.

Reasons Supporting Proposal: This proposed amendment would eliminate a conflict with RCW 48.165.050 and help standardize the deadlines for health carrier responses to preauthorization requests. The proposed changes have been developed through a collaborative process involving health carriers and health care providers and have been endorsed by that group.

Statutory Authority for Adoption: RCW 48.02.060, 48.43.520.

Statute Being Implemented: RCW 48.165.050 and 48.43.520.

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

Name of Proponent: Mike Kreidler, insurance commissioner, governmental.

Name of Agency Personnel Responsible for Drafting: Pete Cutler, P.O. Box 40258, Olympia, WA 98504-0258, (360) 725-9651; Implementation: Beth Berendt, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7117; and Enforcement: Carol Sureau, P.O. Box 40255, Olympia, WA 98504-0255, (360) 725-7050.

No small business economic impact statement has been prepared under chapter 19.85 RCW. None of the current domestic health care service contractors or health maintenance organizations meets the definition of small business under the law. Therefore, no small business economic impact statement is required.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Kacy Scott, P.O. Box 40255, Olympia, WA 98504-0255, phone (360) 725-7041, fax (360) 586-3109, e-mail

June 23, 2010

Mike Kreidler

Insurance Commissioner


AMENDATORY SECTION(Amending Matter No. R 2000-02, filed 1/9/01, effective 7/1/01)

WAC 284-43-410   Utilization review -- Generally.   (1) These definitions apply to this section:

(a) "Concurrent care review request" means any request for an extension of a previously authorized inpatient stay or a previously authorized ongoing outpatient service, e.g., physical therapy, home health, etc.

(b) "Immediate review request" means any request for approval of an intervention, care or treatment where passage of time without treatment would, in the judgment of the provider, result in an imminent emergency room visit or hospital admission and deterioration of the patient's health status. Examples of situations that do not qualify under an immediate review request include, but are not limited to, situations where:

(i) The requested service was prescheduled, was not an emergency when scheduled, and there has been no change in the patient's condition;

(ii) The requested service is experimental or in a clinical trial;

(iii) The request is for the convenience of the patient's schedule or physician's schedule; and

(iv) The results of the requested service are not likely to lead to an immediate change in the patient's treatment.

(c) "Nonurgent preservice review request" means any request for approval of care or treatment where the request is made in advance of the patient obtaining medical care or services and is not an urgent care request.

(d) "Postservice review request" means any request for approval of care or treatment that has already been received by the patient.

(e) "Urgent care review request" means any request for approval of care or treatment where the passage of time could seriously jeopardize the life or health of the patient, seriously jeopardize the patient's ability to regain maximum function, or, in the opinion of a physician with knowledge of the patient's medical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

(((1))) (2) Each carrier shall maintain a documented utilization review program description and written clinical review criteria based on reasonable medical evidence. The program must include a method for reviewing and updating criteria. Carriers shall make clinical review criteria available upon request to participating providers. A carrier need not use medical evidence or standards in its utilization review of religious nonmedical treatment or religious nonmedical nursing care.

(((2))) (3) The utilization review program shall meet accepted national certification standards such as those used by the National Committee for Quality Assurance except as otherwise required by this chapter and shall have staff who are properly qualified, trained, supervised, and supported by explicit written clinical review criteria and review procedures.

(((3))) (4) Each carrier when conducting utilization review shall:

(a) Accept information from any reasonably reliable source that will assist in the certification process;

(b) Collect only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services;

(c) Not routinely require providers or facilities to numerically code diagnoses or procedures to be considered for certification, but may request such codes, if available;

(d) Not routinely request copies of medical records on all patients reviewed;

(e) Require only the section(s) of the medical record during prospective review or concurrent review necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service;

(f) For prospective and concurrent review, base review determinations solely on the medical information obtained by the carrier at the time of the review determination;

(g) For retrospective review, base review determinations solely on the medical information available to the attending physician or order provider at the time the health service was provided;

(h) Not retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan's written policies at the time the care was rendered unless the prior authorization was based upon a material misrepresentation by the provider;

(i) Not retrospectively deny coverage or payment for care based upon standards or protocols not communicated to the provider or facility within a sufficient time period for the provider or facility to modify care in accordance with such standard or protocol; and

(j) Reverse its certification determination only when information provided to the carrier is materially different from that which was reasonably available at the time of the original determination.

(((4))) (5) Each carrier shall reimburse reasonable costs of medical record duplication for reviews.

(((5))) (6) Each carrier shall have written procedures to assure that reviews and second opinions are conducted in a timely manner.

(a) Review ((determinations must be made within two business days of receipt of the necessary information on a proposed admission or service requiring a review determination)) time frames must be appropriate to the severity of the patient condition and the urgency of the need for treatment, as documented in the review request.

(b) ((The frequency of reviews for the extension of initial determinations must be based upon the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity)) If the review request from the provider is not accompanied by all necessary information, the carrier will tell the provider what additional information is needed and the deadline for its submission. Upon the sooner of the receipt of all necessary information or the expiration of the deadline for providing information, the time frames for carrier review determination and notification will be no less favorable than federal Department of Labor standards, as follows:

(i) For immediate request situations, within one business day when the lack of treatment may result in an emergency visit or emergency admission;

(ii) For concurrent review requests, as soon as possible, taking into account the medical exigencies, and no later than twenty-four hours, provided that the request is made at least twenty-four hours prior to the previously approved period of time or number of treatments;

(iii) For urgent care review requests, within forty-eight hours;

(iv) For nonurgent preservice review requests, within five calendar days; or

(v) For postservice review requests, within thirty calendar days.

(c) ((Retrospective review determinations must be completed within thirty days of receipt of the necessary information.

(d))) Notification of the determination shall be provided as follows:

(i) Information about whether a request was approved or denied shall be made available to the attending physician ((or)), ordering provider ((or)), facility, and ((to the)) covered person ((within two days of the determination and shall be provided within one day of concurrent review determination)) on the carrier's web site or from the carrier's call center.

(ii) Whenever there is an adverse determination the carrier shall notify the ordering provider or facility and the covered person. For example, when a request is denied or requested services are not approved in full. The carrier must inform the parties in advance of how it will provide notification whether by phone, mail, fax, or other means.

(d) As appropriate to the type of request, notification shall include the number of extended days, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

(((6))) (e) The frequency of reviews for the extension of initial determinations must be based upon the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity.

(7) No carrier may penalize or threaten a provider or facility with a reduction in future payment or termination of participating provider or participating facility status because the provider or facility disputes the carrier's determination with respect to coverage or payment for health care service.

[Statutory Authority: RCW 48.02.060, 48.18.120, 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.100, 48.46.200, 48.43.505, 48.43.510, 48.43.515, 48.43.520, 48.43.525, 48.43.530, 48.43.535. 01-03-033 (Matter No. R 2000-02), 284-43-410, filed 1/9/01, effective 7/1/01.]

Washington State Code Reviser's Office