Section 284-43-7100 - Required disclosures(1) Plans and issuers must provide reasonable access to and copies of all documents, records, and other information relevant to an individual's claim. (a) Plans and issuers must provide disclosures consistent with WAC 284-43-4040, 284-43-3170, 284-43-3110, and 284-43-2000. For any other disclosures related to an individual's claim, the plan or issuer must provide disclosures within thirty days.(b) When a claim relates to a protected individual, as defined in RCW 48.43.005, the health carrier must comply with RCW 48.43.505.(2) Plans and issuers must provide the criteria, processes, strategies, evidentiary standards and other factors used to make medical necessity determinations of mental health or substance use disorder benefits. These must be made available free of charge by the plan issuer to any current or potential enrollee, beneficiary, or contracting provider upon request, within a reasonable time in compliance with WAC 284-43-2000, and in a manner that provides reasonable access to the requestor. This requirement includes information on the processes, strategies, evidentiary standards, and other factors used to apply an NQTL with respect to medical/surgical and mental health or substance use disorder benefits under the plan.(3) The reason for any adverse benefit decision for mental health or substance use disorder benefits must be provided with the notification of the adverse benefit decision. When an adverse benefit decision relates to a protected individual, as defined in RCW 48.43.005, the health carrier must comply with RCW 48.43.505.(4) Compliance with these disclosure requirements is not determinative of compliance with any other provisions of applicable federal or state law.(5) If a plan is subject to ERISA, it must provide the reason for the claim denial in a form and manner consistent with the requirements of 29 C.F.R. 2560.503-1.Wash. Admin. Code § 284-43-7100
WSR 16-01-081, recodified as § 284-43-7100, filed 12/14/15, effective 12/14/15.Amended by WSR 16-14-106, Filed 7/6/2016, effective 8/6/2016Amended by WSR 20-24-040, Filed 11/23/2020, effective 12/24/2020 Statutory Authority: RCW 48.02.060, 48.43.715, 48.44.050, 48.46.200 and Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, Pub. L. 110-343. WSR 14-23-057 (Matter No. R 2012-29), § 284-43-996, filed 11/17/14, effective 12/18/14.