WA HMO Appeal – Medical Necessity – Qualified Reviewers
Last Updated: January 21, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s failure to reimburse medically necessary services as required by State law. Our investigation has concluded the following: Please be aware that Washington Administrative Code 284-43-3110(6) states: (6) Review of... View more
WA HMO Appeal – No Authorization for ER Services and Care
Last Updated: January 21, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ‘s failure to reimburse emergency services as required by State law. Our investigation has concluded the following: Per Revised Codes of Washington (RCW) 48.43.093(1)(a): (1)(a) A health carrier shall cover... View more
WA HMO Appeal – Non-urgent Authorization Timeframes
Last Updated: January 21, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Washington Office of the Insurance Commissioner (OIC) for ’s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by State law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS... View more
WA HMO Appeal – Notice Requirements for Adverse Determinations
Last Updated: January 21, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s failure to reimburse medically necessary services as required by State law. Our investigation has concluded the following: On , denied this claim as not medically necessary. To date, we... View more
WA HMO Appeal – Poststabilization Timeframe
Last Updated: January 21, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s failure to reimburse emergency and/or statutorily authorized post-stabilization services and care as required by State law. Our investigation has concluded the following: TO DATE, HAS FAILED TO REIMBURSE EMERGENCY... View more
WA HMO Appeal – Refund Recoupment
Last Updated: January 22, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s recoupment of payment for properly reimbursed medically necessary services as required by State law. Our investigation has concluded the following: Please be advised that must meet the written requirements... View more
WA HMO Appeal – Retroactive Denial for Authorized Care
Last Updated: January 22, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s failure to reimburse authorized health services as required by State law. Our investigation has concluded the following: On , authorization number was issued by . Please be advised Revised... View more
WA HMO Appeal – Untimely Payment
Last Updated: January 22, 2025 | Letter Type: Appeals | Jurisdiction: WA HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Office of the Insurance Commissioner (OIC) for ’s failure to timely reimburse this claim as required by State law. Prompt reimbursement of a claim is defined under Washington Administrative Code (WAC) 284-170-431(2)(a): (2)(a) For health services... View more
WA HMO Fax Cover Sheet – Competent Reviewer Request
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: WA HMO
COMPETENT REVIEWER REQUEST : Washington law requires that there is a right to request the identity of the experts who were consulted about the adverse benefit determination—even if the expert’s advice was not used to make the determination, per WAC 284-43-3070. The carrier must provide, at minimum, the expert’s... View more
WA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: WA HMO
REQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1) provide post-stabilization authorization, or (2) enter into a disagreement of care and arrange for the transfer of the patient within 60 minutes from receipt of this notification, per 42 CFR §422.113 and 42 CFR §... View more