Out-of-Network Waiver Request Process

The Embright clinically integrated network (CIN) offers comprehensive care services throughout the Pacific Northwest Region. Beginning January 1, 2022, Embright is responsible for these contracts and member populations:

  • Boeing Preferred Partnership Plan
  • Health Care Authority – UMP Plus UW Medicine ACN 
    • PEBB
    • SEBB

Embright strives to provide our members with a full range of doctors and facilities, so they can get the care they need. We understand that there are rare, unique situations where our members may need to seek care outside of our network. As a provider, here is what you will need to know to determine whether or not our member needs to receive care from an out-of-network provider or facility and how this process works.

WHAT IS OUT-OF-NETWORK CARE?

There may be rare situations where the member and their doctor think the member may need care outside of the Embright network. In these rare situations, the member and their doctor will need to go through a waiver referral process to request out-of-network care as “in-network”. The waiver referral process is limited to approving members to receive care outside of the Embright network and does not guarantee that the services will be covered by their health plan.

WHAT IS THE WAIVER REFERRAL PROCESS?

  1. Determine that receiving care from an out-of-network doctor or facility is the best option for your patient. Types of scenarios that may qualify include:
    • You have confirmed that the care that the member needs is not available within the Embright network.
    • The member is already receiving an active course of treatment from an out-of-network specialist and disruption of that care can jeopardize the member’s health, such as oncology treatment or prenatal care.
    • The care that the member needs is not available in the Embright network within 50 miles of their home or work.
  2. You will submit the Embright waiver request form with accompanying clinical documentation for consideration to your organization’s Medical Director.
    • ​​​​​​​The Embright waiver request form and additional waiver-related resources can be found here.
    • If you have any questions about the waiver process or cannot find the waiver resources, please feel free to reach out to Embright at waivers@embright.com or 425.659.3648.
  3. Your organization’s Medical Director will perform the initial review to approve or deny the request and communicate the decision to you. 
    • If approved by your organization’s Medical Director, they will send the waiver request form to Embright via Egnyte (secured file sharing platform for PHI) or fax at 206.589.6600.
  4. The Embright Medical Director will perform a final review to approve or deny the request at the Embright network level and communicate the decision to you.
    • This process typically takes 3-5 business days.

ADDITIONAL THINGS TO KNOW

Please reach out to the following should you have any questions about the process.

  • Initial waiver request review 
    • For clinical questions or how your organization manages the initial waiver request internally - please reach out to your organization’s Medical Director.
    • You may find the Embright waiver process documents and resources here.
  • Embright waiver request review
    • For questions related to the Embright process or Embright resources, please reach out to Embright at waivers@embright.com or 425.659.3648.
    • The waiver must be submitted and approved before your patient can receive care from the outside provider or facility.
    • Submitting or having an approved waiver request does not guarantee that your patient’s services will be covered under their health plan. They will need to follow up with their health plan should they have any questions about coverage.