State Law

Washington Admin. Code-Title 284-Chapter 284-43-Subchapter E. Adverse Benefit Determination Process Requirements for Nongrandfathered Plans

08/26/2023 Washington Section 284-43-3190

Concurrent expedited review of adverse benefit determinations

State Medical Necessity Appeals-Deadlines

(1) “Concurrent expedited review” means initiation of both the internal and external expedited review simultaneously to:

(a) Review of a decision made under WAC 284-43-2000; or

(b) Review conducted during a patient’s stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting so that the final adverse benefit determination is reached as expeditiously as possible.

(2) A carrier must offer the right to request concurrent expedited internal and external review of adverse benefit determinations. When a concurrent expedited review is requested, a carrier may not extend the timelines by making the determinations consecutively. The requisite timelines must be applied concurrently.

(3) A carrier may deny a request for concurrent expedited review only if the conditions for expedited review in WAC 284-43-3170 are not met. A carrier may not require exhaustion of internal review if an appellant requests concurrent expedited review.