State Law

Washington Admin Code-Title 284-Chapter 284-170-Subchapter C. Provider Contracts and Payment

08/28/2023 Washington Section 284-170-411

Selection of participating providers-Credentialing and unfair discrimination

Credentialing-Patient Demographics

See bold text below:

(1) An issuer must develop standards for selecting participating providers, for primary care providers, and for each health care provider or facility license and professional specialty. The standards must be used in determining the selection of health care providers and facilities by the issuer. The standards must be consistent with rules or standards established by the state department of health or other regulatory authority established in Title 18 RCW for health care providers specified in RCW 18.130.040. Selection criteria must not be established in a manner that would:

(a) Allow an issuer to avoid risk by excluding providers or facilities because they are located in geographic areas that contain populations presenting a risk of higher than average claims, losses, or health services utilization;

(b) Exclude providers or facilities because they treat or specialize in treating persons presenting a risk of higher than average claims, losses, or health services utilization or because they treat or specialize in treating minority or special populations; or

(c) Discriminate regarding participation in the network solely based on the provider or facility type or category if the provider is acting within the scope of their license.

(2) The provisions of subsection (1) of this section must not be construed to prohibit an issuer from declining to select a provider or facility who fails to meet other legitimate selection criteria of the issuer. The purpose of these provisions is to prevent prohibited health risk avoidance or prohibited discrimination through network creation and provider or facility selection.

(3) The provisions of this subchapter do not require an issuer to employ, to contract with, or retain more providers or facilities than are necessary to comply with the network access standards of this chapter.

(4) An issuer must make its selection standards for participating providers and facilities available for review upon request by the commissioner.