Title 48 — Title 48 INSURANCE
101 chapters · 2,134 sections in this title.
RCW 48.200.010 Findings—Intent.
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(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 carrier…
RCW 48.200.020 Definitions.
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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 cont…
RCW 48.200.030 Registration requirements—Application—Fees—Retention of transaction records.
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(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 for…
RCW 48.200.040 Contract requirements—Written agreement describing rights and responsibilities—Filing of contracts—Confidentiality.
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(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 r…
RCW 48.200.050 Inquiries or complaints—Violations of chapter—Enforcement actions—Responsibility of carriers and programs for compliance.
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(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 t…
RCW 48.200.210 Definitions applicable to RCW 48.200.220 through 48.200.290.
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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 fr…
RCW 48.200.220 Definitions applicable to RCW 48.200.220 through 48.200.290.
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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 proc…
RCW 48.200.230 Basis of finding of claim.
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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…
RCW 48.200.240 Contract with third party—Prohibited practices.
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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 enti…
RCW 48.200.250 Evidence of validation of claim.
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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, with…
RCW 48.200.260 Preliminary audit report—Dispute or denial of claim—Final audit report—Recoupment of disputed funds.
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(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…
RCW 48.200.270 Application.
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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 o…
RCW 48.200.280 Predetermination of reimbursement costs—Appeals—Review by commissioner.
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(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 predetermined reimbursement costs have been established, such as a maximum allowable cost or maximum allowable cost list…
RCW 48.200.290 Definitions applicable to RCW 48.200.220 through 48.200.290.
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(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 und…
RCW 48.200.300 Service of process.
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(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 cons…
RCW 48.200.310 Prohibitions and duties.
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(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;…
RCW 48.200.320 Prohibitions on retaliation.
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(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 vio…
RCW 48.200.330 Application—Plans governed by the federal employee retirement income security act.
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(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 un…
RCW 48.200.900 Rule making—2020 c 240.
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The insurance commissioner may adopt any rules necessary to implement this act.[ 2020 c 240 s 20.]
RCW 48.200.901 Effective date—2020 c 240.
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Sections 1 through 19 of this act take effect January 1, 2022.[ 2020 c 240 s 23.]