Wash. Admin. Code § 284-43A-130

Current through Register Vol. 24-21, November 1, 2024

Section 284-43A-130 - 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 or investigational 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 commissioner may take action as described in WAC 284-43A-120.

Wash. Admin. Code § 284-43A-130

Adopted by WSR 16-23-168, Filed 11/23/2016, effective 1/1/2017