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WACs > Title 246 > Chapter 246-305 > Section 246-305-990











246-305-110    

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WAC 246-305-990









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 department may take action as described in WAC 246-305-110.
[Statutory Authority: RCW 43.70.235 and 48.43.535. WSR 11-23-124, § 246-305-990, filed 11/21/11, effective 11/26/11. Statutory Authority: 2005 c 54. WSR 05-24-029, § 246-305-990, filed 11/30/05, effective 12/31/05.]