Washington · statute · Wash. Rev. Code ch. 48.200 · 20 active provisions
(1) The legislature finds that growth in managed health care systems has shifted substantial authority over health care decisions from providers and patients to health carriers and health care benefit managers. Health care benefit managers acting as intermediaries between carriers, health care providers, and patients e…
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.(1) "Affiliate" or "affiliated employer" means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, another specified person.(2) "…
(1) To conduct business in this state, a health care benefit manager must register with the commissioner and annually renew the registration.(2) To apply for registration with the commissioner under this section, a health care benefit manager must:(a) Submit an application on forms and in a manner prescribed by the com…
(1) A health care benefit manager may not provide health care benefit management services to a health carrier or employee benefits programs without a written agreement describing the rights and responsibilities of the parties conforming to the provisions of this chapter and any rules adopted by the commissioner to impl…
(1) Upon notifying a carrier or health care benefit manager of an inquiry or complaint filed with the commissioner pertaining to the conduct of a health care benefit manager identified in the inquiry or complaint, the commissioner must provide notice of the inquiry or complaint to the health care benefit manager. Notic…
The definitions in this section apply throughout this section and RCW 48.200.220 through 48.200.290 unless the context clearly requires otherwise.(1) "Audit" means an on-site or remote review of the records of a pharmacy by or on behalf of an entity.(2) "Claim" means a request from a pharmacy or pharmacist to be reimbu…
An entity that audits claims or an independent third party that contracts with an entity to audit claims:(1) Must establish, in writing, a procedure for a pharmacy to appeal the entity's findings with respect to a claim and must provide a pharmacy with a notice regarding the procedure, in writing or electronically, pri…
An entity's finding that a claim was incorrectly presented or paid must be based on identified transactions and not based on probability sampling, extrapolation, or other means that project an error using the number of patients served who have a similar diagnosis or the number of similar prescriptions or refills for si…
An entity that contracts with an independent third party to conduct audits may not:(1) Agree to compensate the independent third party based on a percentage of the amount of overpayments recovered; or(2) Disclose information obtained during an audit except to the contracting entity, the pharmacy subject to the audit, o…
For purposes of RCW 48.200.210 through 48.200.270, an entity, or an independent third party that contracts with an entity to conduct audits, must allow as evidence of validation of a claim:(1) An electronic or physical copy of a valid prescription if the prescribed drug was, within fourteen days of the dispensing date:…
(1)(a) After conducting an audit, an entity must provide the pharmacy that is the subject of the audit with a preliminary report of the audit. The preliminary report must be received by the pharmacy no later than forty-five days after the date on which the audit was completed and must be sent:(i) By mail or common carr…
RCW 48.200.210 through 48.200.270 do not:(1) Preclude an entity from instituting an action for fraud against a pharmacy;(2) Apply to an audit of pharmacy records when fraud or other intentional and willful misrepresentation is indicated by physical review, review of claims data or statements, or other investigative met…
(1) The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.(a) "List" means the list of drugs for which reimbursement costs have been established to determine reimbursement amounts.(b) "Multiple source drug" means any covered outpatient prescription drug for which…
(1) The commissioner shall have enforcement authority over this chapter and shall have authority to render a binding decision in any dispute between a pharmacy benefit manager, or third-party administrator of prescription drug benefits, and a pharmacy arising out of an appeal under *RCW 48.200.280(6) regarding drug pri…
(1) Each health care benefit manager must appoint the commissioner as its attorney to receive service of, and upon whom must be served, all legal process issued against it in this state for causes of action arising within this state. Service upon the commissioner as attorney constitutes service upon the health care ben…
(1) A pharmacy benefit manager may not:(a) Reimburse a network pharmacy an amount less than the contract price between the pharmacy benefit manager and the insurer, third-party payor, or the prescription drug purchasing consortium the pharmacy benefit manager has contracted with;(b) Require a covered person to pay more…
(1) A pharmacy benefit manager may not retaliate against a pharmacist or pharmacy for disclosing information in a court, in an administrative hearing, or legislative hearing, if the pharmacist or pharmacy has a good faith belief that the disclosed information is evidence of a violation of a state or federal law, rule,…
(1) Nothing in chapter 242, Laws of 2024 expands or restricts the entities subject to this chapter. Therefore, except as provided in subsection (2) of this section, this chapter continues to be inapplicable to a person or entity providing services to, or acting on behalf of, a union or employer administering a self-fun…
The insurance commissioner may adopt any rules necessary to implement this act.
Sections 1 through 19 of this act take effect January 1, 2022.