Access to care
Under Washington state law, some health plans must allow patients to access every type of licensed medical provider.
Health plans must also have a network with enough providers so patients can access covered services in a reasonable amount of time.
Note: We can't force insurers to work with a specific medical provider or facility. Insurers and providers agree on contracts and reimbursement rates privately.
Billing and refunds
If you have a contract with an insurer, the health plan must meet the following minimum standards when paying claims:
- Within 30 days, they must pay 95% of monthly claims that have all the information the health plan needs to pay on time.
- Within 60 days, they must pay or deny 95% of all monthly claims.
Under Washington state law, insurers have 24 months to ask you for a refund after paying a claim. They must send you a written request that explains why they believe you owe a refund. An electronic message is OK. You have 30 days from the date of the notice to send a written disagreement to the company.
If you have a contract with an insurer, you can't bill your patient more than what their plan says they owe. Even if you don't have a contract, there are some cases when this still applies. Learn more about balance billing.
How to resolve disagreements with insurers
Insurers you have contracts with must have dispute resolution processes for their health plans. For billing disagreements, insurers must make a decision within 60 days of receiving your complaint. Contact the company or check your contract to learn more about how this works.
You can also file a complaint with us, and we can review your concerns with the company. If your complaint includes personal information about a patient, you must provide their signed consent
Patients can also appeal a claim their health plan denies.
Not all coverage must follow these requirements
State health insurance laws don't apply to all insurance policies or medical programs we don't regulate (Medicare, Apple Health and TRICARE). Washington state law doesn't recognize the following insurance policies as health plans:
- Accident-only coverage
- Fixed payment indemnity insurance
- Critical illness coverage
- Limited health care services
- Coverage through an auto or homeowner personal injury claim
- Long-term care insurance
- Dental-only and vision-only coverage
- Medicare Supplement (Medigap) plans
- Disability-income insurance
- Short-term limited purpose insurance
- Health plans employers fund
- Workers compensation coverage