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296-20-01020  <<  296-20-01030 >>   296-20-01040

WAC 296-20-01030

Agency filings affecting this section

Minimum health care provider network standards.

The department will deny an application if a provider does not meet minimum health care provider network standards. To be eligible for enrollment and participation in the provider network, a provider must meet and maintain the following minimum health care provider network standards:
(1) The provider must submit an accurate and complete provider application, including any required supporting documentation and sign without modification, a provider agreement with the department.
(2) The provider must have current professional liability coverage, individually or as a member of a group, through a commercial carrier or provide documentation of self-insurance.
(a) Professional liability coverage must be at least in the amounts of one million dollars per occurrence and three million dollars annual aggregate; or in the amounts otherwise published by the department for the provider type's scope of practice, after notice and opportunity for comment.
(b) Providers in a group practice who are self-insured for professional liability coverage must provide evidence that liabilities in amounts at least equivalent to liability limits in (a) of this subsection are booked on audited financial statements in accordance with generally accepted accounting standards.
(3) The provider must not have had clinical admitting and management privileges denied, limited or terminated for quality of care issues.
(4) The provider must not have been excluded, expelled, terminated, or suspended from any federally or state funded health care programs including, but not limited to, medicare or medicaid programs based on cause or quality of care issues.
(5) The provider must not have made any material misstatement or omission to the department concerning licensure, registration, certification, disciplinary history or any other material matter covered in the application or credentialing materials.
(6) The provider must not have been convicted of a felony or pled guilty or no contest to a felony for a crime including, but not limited to, health care fraud, patient abuse and the unlawful manufacture, distribution, prescription or dispensing of controlled substances.
The department may grant an exception for a felony that the provider has had expunged (vacated criminal conviction) from the provider's record.
(7) The provider must be currently licensed, certified, accredited or registered according to Washington state laws and rules or in any other jurisdiction where the applicant treats injured workers.
(a) The license, registration or certification must be free of any restrictions, limitations or conditions relating to the provider's clinical practice.
(b) The provider must not have surrendered, voluntarily or involuntarily his or her professional state license in any state while under investigation or due to findings by the state resulting from the provider's acts, omissions, or conduct.
(c) The department may grant an exception for any restriction, limitation or condition deemed by the department to be minor or clerical in nature or for a case where the restriction, limitation, or condition has been removed.
(8) The provider must have a current Drug Enforcement Administration (DEA) registration, if applicable to the provider's scope of licensure.
(a) The DEA registration must be free of restrictions, limitations or conditions related to the provider's acts, omissions or conduct.
(b) The provider must not have surrendered, voluntarily or involuntarily his or her DEA registration in any state while under investigation or due to findings resulting from the provider's acts, omissions, or conduct.
(c) The department may grant an exception for any restriction, limitation or condition deemed by the department to be minor or clerical in nature or for a case where the restriction, limitation or condition has been removed.
[Statutory Authority: RCW 51.36.010, 51.04.020, and 51.04.030. WSR 12-02-058, ยง 296-20-01030, filed 1/3/12, effective 2/3/12.]