Sec. 21.07.060. - Qualifications of external appeal agencies.
(a) An external appeal agency qualifies to consider external appeals if, with respect to a managed care plan, the agency is certified by a qualified private standard-setting organization approved by the director or by a health insurer operating in this state as meeting the requirements imposed under (b) of this section.
(b) An external appeal agency is qualified to consider appeals of managed care plan health care decisions if the agency meets the following requirements:
(1) the agency meets the independence requirements of this section;
(2) the agency conducts external appeal activities through a panel of two clinical peers, unless otherwise agreed to by both parties; and
(3) the agency has sufficient medical, legal, and other expertise and sufficient staffing to conduct external appeal activities for the managed care entity on a timely basis consistent with this chapter.
(c) A clinical peer or other entity meets the independence requirements of this section if
(1) the peer or entity does not have a familial, financial, or professional relationship with a related party;
(2) compensation received by a peer or entity in connection with the external review is reasonable and not contingent on any decision rendered by the peer or entity;
(3) the plan and the issuer have no recourse against the peer or entity in connection with the external review; and
(4) the peer or entity does not otherwise have a conflict of interest with a related party.
(d) In this section, "related party" means
(1) with respect to
(A) a managed care plan, the plan or the insurer offering the coverage; or
(B) individual health insurance coverage, the insurer offering the coverage, or any plan sponsor, fiduciary, officer, director, or management employee of the plan or issuer;
(2) the health care professional that provided the health care involved in the coverage decision;
(3) the institution at which the health care involved in the coverage decision is provided;
(4) the manufacturer of any drug or other item that was included in the health care involved in the coverage decision;
(5) the covered person; or
(6) any other party that, under the regulations that the director may prescribe, is determined by the director to have a substantial interest in the coverage decision.