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RCW 48.43.016 (Prior Authorizations)

8 Feb 2021 11:50 PM | Robbin Blake (Administrator)

RCW 48.43.016 “Prior Authorization Standards and Criteria—Health carrier Requirements—Definitions”.  On March 22, 2020, the Governor signed into law ESB 5887 which amends RCW 48.43.016.  This is the RCW amendment which went into effect in June 2018 which provided for 6 consecutive treatment visits for massage therapy and other occupational therapies for plans requiring preauthorization. This 2018 amendment was meant to create stability of care with Premera and Regence patients/clients processed through eviCore.  Unfortunately, health insurance companies managed to create their own interpretation of this law which created havoc when trying to provide the continuity of care for our patients/clients using these plans, for the past two years. 

With this new 2020 bill, each patient may have “six treatment visits with a contracting provider in a new episode of care for each of the following: Chiropractic, physical therapy, occupational therapy, acupuncture, Eastern medicine, massage therapy, or speech and hearing therapies”.  Whereas the health carriers were interpreting this as “six sessions total” regardless of which profession provided service, it now clearly states 6 sessions per profession. The other major change is the health carrier cannot “deny or limit coverage on the basis of medical necessity or appropriateness or retroactively deny care or refuse payment for the visits”.  If you go to https://apps.leg.wa.gov/RCW/default.aspx?cite=48.43.016, you can review the current RCW and there is a link to see the new language which went into effect on 6/11/20.


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