Current through Register Vol. 24-06, March 15, 2024
(1)
(a) To initiate arbitration, the carrier,
provider, or facility must provide written notification to the commissioner and
the noninitiating party no later than 10 calendar days following completion of
the period of good faith negotiation under WAC
284-43B-030(3)
using the arbitration initiation request form found in Appendix A of this rule.
A request must be submitted electronically through the website of the office of
the insurance commissioner. When multiple claims are addressed in a single
arbitration proceeding, subsection (3) of this section governs calculation of
the 10 calendar days. Each arbitration initiation request must be submitted to
the commissioner individually and constitutes a distinct arbitration proceeding
unless consolidation of requests is authorized by a court under chapter 7.04A
RCW. The commissioner will assign a unique number or designation to each
arbitration initiation request. The parties must include that designation in
all communication related to that request. Any information submitted to the
commissioner with the arbitration initiation request must be included in the
notice to the nonini-tiating party under
RCW
48.49.040. A provider or facility initiating
arbitration must send the arbitration initiation request form to the email
address appearing on the website established by the designated lead
organization for administration simplification in Washington state under (c) of
this subsection. Any patient information submitted to the commissioner with an
arbitration initiation request form must be de-identified to ensure that
protected health information is not disclosed.
(b) The written notification to the
commissioner must be made electronically and provide dates related to each of
the time period limitations described in WAC
284-43B-030(1) through
(3) and subsection (1)(a) of this section.
The commissioner's review of the arbitration initiation request form is limited
to the information necessary to determine that the request has been timely
submitted and is complete. The commissioner's review does not include a review
of whether particular claims included in the request are subject to chapter
48.49 RCW or whether claims are appropriately bundled under subsection (3) of
this section. A party seeking to challenge whether a claim is subject to
chapter 48.49 RCW or whether claims are appropriately bundled may raise those
issues during arbitration.
(c) Each
carrier must provide the designated lead organization for administrative
simplification in Washington state with the email address and telephone number
of the carrier's designated contact for receipt of notices to initiate
arbitration. The email address and phone number provided must be specific to
the carrier staff responsible for receipt of notices or other actions related
to arbitration proceedings. The initial submission of information to the
designated lead organization must be made on or before November 10, 2020. The
carrier must keep its contact information accurate and current by submitting
updated contact information to the designated lead organization as directed by
that organization.
(2)
Within 10 business days of a party notifying the commissioner and the
noninitiating party of intent to initiate arbitration, both parties shall agree
to and execute a nondisclosure agreement. The nondisclosure agreement must
prohibit either party from sharing or making use of any confidential or
proprietary information acquired or used for purposes of one arbitration in any
subsequent arbitration proceedings. The nondisclosure agreement must not
preclude the arbitrator from submitting the arbitrator's decision to the
commissioner under
RCW
48.49.040 or impede the commissioner's duty
to prepare the annual report under
RCW
48.49.050.
(3) If a nonparticipating provider or
nonparticipating facility chooses to address multiple claims in a single
arbitration proceeding as provided in
RCW
48.49.040, notification must be provided no
later than 10 calendar days following completion of the period of good faith
negotiation under WAC
284-43B-030(3)
for the most recent claim that is to be addressed through the arbitration. All
of the claims at issue must:
(a) Involve
identical carrier and provider, provider group or facility parties. Items and
services are billed by the same provider, provider group or facility if the
items or services are billed with the same national provider identifier or tax
identification number;
(b) Involve
the same or similar items and services. The services are considered to be the
same or similar items or services if each is billed under the same service
code, or a comparable code under a different procedural code system, such as
current procedural terminology (CPT) codes with modifiers, if applicable,
health care common procedure coding system (HCPCS) with modifiers, if
applicable, or diagnosis-related group (DRG) codes with modifiers, if
applicable; and
(c) Occur within
the same 30 business day period of one another, such that the earliest claim
that is the subject of the arbitration occurred no more than 30 business days
prior to the latest claim that is the subject of the arbitration. For purposes
of this subsection, a provider or facility claim occurs on the date the service
is provided to a patient or, in the case of inpatient facility admissions, the
date the admission ends.
(4) A notification submitted to the
commissioner later than 10 calendar days following completion of the period of
good faith negotiation will be considered untimely and will be rejected. Any
revision to a previously timely submitted arbitration initiation request form
must be submitted to the commissioner within the 10 calendar day period
applicable to submission of the original request. A party that has submitted an
untimely notice is permanently foreclosed from seeking arbitration related to
the claim or claims that were the subject of the untimely notice.
(5) Within seven calendar days of receipt of
notification from the initiating party, the commissioner must provide the
parties with a list of approved arbitrators or entities that provide
arbitration. The commissioner will use the email addresses for the initiating
party and the noninitiating party indicated on the arbitration initiation
request form for all communication related to the arbitration request. The
arbitrator selection process must be completed within 20 calendar days of
receipt of the original list of arbitrators from the commissioner, as follows:
(a) If the parties are unable to agree on an
arbitrator from the original list sent by the commissioner, they must notify
the commissioner within five calendar days of receipt of the original list of
arbitrators. The commissioner must send the parties a list of two individual
arbitrators and three arbitration entities within five calendar days of receipt
of notice from the parties under this subsection. Each party is responsible for
reviewing the list of five arbitrators and arbitration entities and notifying
the commissioner and the other party within three calendar days of receipt of
the list:
(i) Whether they are taking the
opportunity to veto up to two of the five arbitrators or arbitration entities
on this list, and if so, which arbitrators or arbitration entities have been
vetoed; and
(ii) If there is a
conflict of interest as described in subsection (6) of this section with any of
the arbitrators or arbitration entities on the list, to avoid the commissioner
assigning an arbitrator or arbitration entity with a conflict of interest to an
arbitration.
(b) If,
after the opportunity to veto up to two of the five named arbitrators or
arbitration entities on the list of five arbitrators and arbitration entities
sent by the commissioner to the parties, more than one arbitrator or
arbitration entity remains on the list, the parties must notify the
commissioner within five calendar days of receipt of the list of five
arbitrators or arbitration entities. The commissioner will choose the
arbitrator from among the remaining arbitrators on the list. If a party fails
to timely provide the commissioner with notice of their veto, the commissioner
will choose the arbitrator from among the remaining arbitrators or arbitration
entities on the list.
(6)
Before accepting any appointment, an arbitrator shall ensure that there is no
conflict of interest that would adversely impact the arbitrator's independence
and impartiality in rendering a decision in the arbitration. A conflict of
interest includes (a) current or recent ownership or employment of the
arbitrator or a close family member by any health carrier; (b) serves as or was
employed by a physician, health care provider, or a health care facility; (c)
has a material professional, familial, or financial conflict of interest with a
party to the arbitration to which the arbitrator is assigned.
(7) For purposes of this subsection, the date
of receipt of a list of arbitrators is the date of electronic transmittal of
the list to the parties by the commissioner. The date of receipt of notice from
the parties to the commissioner is the date of electronic transmittal of the
notice to the commissioner by the parties.
(8) If a noninitiating party fails to timely
respond without good cause to a notice initiating arbitration, the initiating
party will choose the arbitrator.
(9) Where a dispute resolution matter
initiated under sections 2799A-1 and 2799A-2 of the Public Health Service Act
(42 U.S.C. Secs. 300gg-111 and 300gg-112) and federal regulations implementing
those provisions of P.L.
116-260 (enacted December 27, 2020) results in a
determination by a certified independent dispute resolution entity that such
process does not apply to the dispute or to portions thereof,
RCW
48.49.040(3)(b) governs
initiation of arbitration under this chapter.