West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-58 - External Review Of Coverage Denials
Section 114-58-7 - Binding Nature of External Review Decision
Current through Register Vol. XLI, No. 38, September 20, 2024
7.1. An external review decision is binding on the managed care plan.
7.2. An external review decision is binding on the enrollee except to the extent the enrollee has other remedies available under federal or state law.
7.3. An enrollee or an enrollee's authorized representative may not file a subsequent request for external review involving the same adverse determination for which the enrollee has already received an external review decision pursuant to W. Va. Code '33-25C-6 and this rule.
7.4. The external review organization may not order the managed care plan to provide a benefit or to pay a claim for a benefit that is excluded from coverage by the plan.
