Each carrier's review process must require delivery of written notification of the internal review determination to the appellant. In addition to the requirements of WAC 284-43-3070, the written determination must include:

1. (1) The actual reasons for the determination;
2. (2) If applicable, instructions for obtaining further review of the determination, either through a second level of internal review, if applicable, or using the external review process;
3. (3) The clinical rationale for the decision, which may be in summary form; and
4. (4) Instructions on obtaining the clinical review criteria used to make the determination;
5. (5) A statement that the appellant has up to one hundred eighty days to file a request for external review, and that if review is not requested, the internal review decision is final and binding.

[Statutory Authority: RCW 48.02.060. WSR 16-14-106 (Matter No. R 2016-11), § 284-43-3150, filed 7/6/16, effective 8/6/16. WSR 16-01-081, recodified as § 284-43-3150, filed 12/14/15, effective 12/14/15. Statutory Authority: RCW 48.02.060, 48.43.525, 48.43.530, 48.43.535, and The Patient Protection and Affordable Care Act, P.L. 111-148, as amended (2010). WSR 12-23-005 (Matter No. R 2011-11), § 284-43-535, filed 11/7/12, effective 11/20/12.]