West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-95 - Utilization Review and Benefit Determination
Section 114-95-1 - General

Universal Citation: 114 WV Code of State Rules 114-95-1

Current through Register Vol. XLI, No. 38, September 20, 2024

1.1. Scope. - This rule establishes standards and criteria for the structure and operation of utilization review and benefit determination, processes designed to facilitate ongoing assessment and management of health care services. This rule applies to any issuer offering a health benefit plan that provides or performs utilization review services, including prospective review or retrospective review benefit determinations and to any designee of the issuer or any utilization review organization that performs such functions on the issuer's behalf. This rule is based on the National Association of Insurance Commissioners' "Utilization Review Model Act" (Model 73), as amended in 2012.

1.2. Authority. - W. Va. Code § 33-2-10 & § 33-16H-4.

1.3. Filing Date.-June 6,2014.

1.4. Effective Date.--July 6, 2014.

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