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PDFWAC 284-30-770

Adverse notification requirements.

(1) This section applies to all insurers, fraternal benefit societies, health carriers including disability, health maintenance organizations (HMOs), health care service contractors (HCSCs), and limited licensed carriers, and to all insurance policies, health plans, and insurance contracts.
(2) For the purpose of this section only the term "Adverse notification" means a notice, statement, or document from an insurer, fraternal benefit societies, health carriers including disability, HMOs, HCSCs, and limited licensed carriers to their insured, or enrollee, or both, describing one or more of the following:
(a) A claim denial;
(b) A final claim payment for less than the amount of the claim submitted. This does not include a claim that is paid less than the original amount to reflect the contracted health care provider's rate;
(c) An adverse benefit determination as defined in RCW 48.43.005(2); and
(d) Rescission, cancellation, termination or nonrenewal of a policy unless initiated by an insured. This does not apply to the end of a scheduled policy term or cancellation due to nonpayment of premium.
(3) On each adverse notification provided, the notice must include the following information:
"If you have questions or concerns about the actions of your insurance company or agent, or would like information on your rights to file an appeal, contact the Washington state Office of the Insurance Commissioner's consumer protection hotline at 1- 800-562-6900 or visit The insurance commissioner protects and educates insurance consumers, advances the public interest, and provides fair and efficient regulation of the insurance industry."
(4) The notice specified in subsection (3) of this section must be in the same font type and not less than the font size of the majority of the notification. This notice must appear on the first page, at the end of the adverse notification, or where this notice currently exists if adverse notices are already provided to insureds.
[Statutory Authority: RCW 48.02.060, 48.18.545, 48.19.035, 48.43.525, and 48.43.535. WSR 20-03-113 (Matter No. R 2019-09), ยง 284-30-770, filed 1/16/20, effective 8/1/20.]
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