For Consumers

What medical providers need to know about health insurance

In addition to consumers, we also hear from medical providers with questions about health insurance. As a medical provider, learn more about your rights and responsibilities for the health plans we regulate.

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 an adequate provider network (leg.wa.gov) that ensures patients have timely access to covered services.

Note: The Office of the Insurance Commissioner doesn't have the authority to require insurance companies to contract with a specific medical provider or facility. These contracts and reimbursement rates are privately negotiated agreements between insurance companies and medical providers.

Billing and reimbursement

As a contracted medical provider, your agreement with the insurance company requires the health plan to meet the following minimum standards (leg.wa.gov) when paying claims; 95 percent of the monthly volume of:

  • Clean claims must be paid within 30 days (a claim that isn't missing information or documentation that prevents the health plan from paying on time).
  • All claims must be paid or denied within 60 days.

Under Washington state law (leg.wa.gov), an insurance company has 24 months to request a refund from a medical provider after it pays a claim. The company must request this refund in writing (an electronic notification is considered acceptable) and specify why it believes you owe a refund. You have 30 days from the date of the notice to contest the request in writing to the company.

If you're a contracted medical provider, you cannot balance bill (leg.wa.gov) your patient (billing your patient the difference between what the health plans reimburses you and what you charge).

How to resolve disputes with insurance companies

Your medical provider contract with an insurance company requires the health plan to have a formal dispute resolution process (leg.wa.gov). For billing disputes, the company must make a decision within 60 days of receiving your complaint. Please contact the company or review your contract for further information on this process.

You can also file a complaint with our office, and we can review your concerns with the company. If you provide any personal information about your patient in the complaint, you must include their signed consent.

For claim denials, your patient will also have the opportunity to appeal a claim denial with his or her health plan.

Not all coverage is subject to these requirements

State health insurance laws don't apply to all insurance policies, or medical programs we don't regulate (Medicare, Apple Health, TRICARE). The following insurance policies aren't recognized as health plans under Washington state law (app.leg.wa.gov):

  • 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

  • Employer-sponsored self-funded health plans

  • Workers compensation coverage