48.43.725  <<  48.43.730 >>   48.43.731

Carrier must file provider contracts and compensation agreements with commissionerApproval or disapprovalConfidentialityHearingsRulesDefinitions.

(1) For the purposes of this section:
(a) "Carrier" means a:
(i) Health carrier as defined in RCW 48.43.005; and
(ii) Limited health care service contractor that offers limited health care service as defined in RCW 48.44.035.
(b) "Provider" means:
(i) A health care provider as defined in RCW 48.43.005;
(ii) A participating provider as defined in RCW 48.44.010;
(iii) A health care facility, as defined in RCW 48.43.005; and
(iv) Intermediaries that have agreed in writing with a carrier to provide access to providers under this subsection (1)(b) who render covered services to enrollees of a carrier.
(c) "Provider compensation agreement" means any written agreement that includes specific information about payment methodology, payment rates, and other terms that determine the remuneration a carrier will pay to a provider.
(d) "Provider contract" means a written contract between a carrier and a provider for any health care services rendered to an enrollee.
(2) A carrier must file all provider contracts and provider compensation agreements with the commissioner thirty calendar days before use. When a carrier and provider negotiate a provider contract or provider compensation agreement that deviates from a filed agreement, the carrier must also file that specific contract or agreement with the commissioner thirty calendar days before use.
(a) Any provider contract and related provider compensation agreements not affirmatively disapproved by the commissioner are deemed approved, except the commissioner may extend the approval date an additional fifteen calendar days upon giving notice before the expiration of the initial thirty-day period.
(b) Changes to previously filed and approved provider compensation agreements modifying the compensation amount or related terms that help determine the compensation amount must be filed and are deemed approved upon filing if no other changes are made to the previously approved provider contract or compensation agreement.
(3) The commissioner may not base a disapproval of a provider compensation agreement on the amount of compensation or other financial arrangements between the carrier and the provider, unless that compensation amount causes the underlying health benefit plan to otherwise be in violation of state or federal law. This subsection does not grant the commissioner the authority to regulate provider reimbursement amounts.
(4) The commissioner may withdraw approval of a provider contract or provider compensation agreement at any time for cause.
(5) Provider compensation agreements are confidential and not subject to public inspection under RCW 48.02.120(2), or public disclosure under chapter 42.56 RCW, if filed in accordance with the procedures for submitting confidential filings through the system for electronic rate and form filings and the general filing instructions as set forth by the commissioner. In the event the referenced filing fails to comply with the filing instructions setting forth the process to withhold the compensation agreement from public inspection, and the carrier indicates that the compensation agreement is to be withheld from public inspection, the commissioner shall reject the filing and notify the carrier through the system for electronic rate and form filings to amend its filing to comply with the confidentiality filing instructions.
(6) In the event a provider contract or provider compensation agreement is disapproved or withdrawn from use by the commissioner, the carrier has the right to demand and receive a hearing under chapters 48.04 and 34.05 RCW.
(7) Provider contracts filed pursuant to subsection (2) of this section shall identify the network or networks to which the contract applies.
(8) The commissioner may adopt rules to implement this section.


FindingsIntentEffective date2019 c 427: See RCW 48.49.003 and 48.49.900.
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