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 114-95-7 - Procedures for Standard Utilization Review and Benefit Determinations

Universal Citation: 114 WV Code of State Rules 114-95-7

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

7.1. Time periods.

7.1.a. Written procedures. An issuer shall maintain written procedures pursuant to this section for making standard utilization review and benefit determinations on requests submitted to the issuer by covered persons and for notifying covered persons of its determinations with respect to these requests within the specified time frames required under this section.

7.1.b. Calculation of days. For purposes of calculating the time periods within which prospective and retrospective review determinations are required to be made, the time period within which the determination is required to be made shall begin on the date the request is received by the issuer in accordance with the issuer's procedures established pursuant to section 5 for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.

7.1.c. Prospective review determinations. Within a reasonable period of time appropriate to the covered person's medical condition but in no event later than fifteen days after receiving the request for a prospective review determination, an issuer shall notify the covered person of such determination.

7.1.d. Retrospective review determinations. For retrospective review determinations, an issuer shall notify the covered person of such determination within a reasonable period of time, but in no event later than thirty days after receiving the benefit request,

7.1.e. Concurrent review determinations. For a concurrent review determination, if an issuer has previously certified an ongoing course of treatment to be provided over a period of time or number of treatments:
7.1.e.1. Any reduction or termination by the issuer during the course of treatment before the end of the period or number of treatments, other than by health benefit plan amendment or termination of the health benefit plan, shall constitute an adverse determination;

7.1.e.2. The issuer shall notify the covered person of the adverse determination in accordance with subsection 7.3 at a time sufficiently in advance of the reduction or termination to allow the covered person to file a grievance to request a review of the adverse determination pursuant to W.Va. Code of St. R. § 114 -96-1 et seq. and obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated; and

7.1.e.3. The health care service or treatment that is the subject of the adverse determination shall be continued without liability to the covered person with respect to the internal review request made pursuant to W.Va, Code of St. R. § 114 -96-1 et seq.

7.1.f Extensions.
7.1.f.1. The time period for making a prospective or retrospective review determination and notifying the covered person of such determination pursuant to subdivision 7.1 .a may be extended one time by the issuer for up to fifteen days, provided the issuer determines that an extension is necessary due to matters beyond the its control and notifies the covered person, prior to the expiration of the initial fifteen-day time period for a prospective review and the expiration of the initial thirty-day time period for a retrospective review, of the circumstances requiring the extension of time and the date by which the issuer expects to make a determination.

7.1.f.2. If the extension under this subdivision is necessary due to the failure of the covered person to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person at least forty-five days from the date of receipt of the notice to provide the specified information.

7.2. Failure to meet issuer's filing procedures.

7.2.a. Whenever the issuer receives a prospective or retrospective review request from a covered person that fails to meet the issuer's filing procedures, the issuer shall notify the covered person within five days of this failure and provide in the notice information on the proper procedures to be followed for filing a request; such notice tolls the time periods in which the issuer must make its determination until the earlier of the date on which the covered person responds to the request for additional information or the date on which the specified information was to have been submitted, and the issuer may deny the certification of the requested benefit if the covered person fails to respond within the extended period.

7.2.b. The provisions of subdivision 7.2.a only apply in the case of a failure that is a communication by a covered person that is received by a person or organizational unit of the issuer responsible for handling benefit matters and that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment or provider for which certification is being requested.

7.3. Adverse determinations.

7.3.a. A notification of an adverse determination under this section shall, in a manner calculated to be understood by the covered person, set forth:
7.3.a.1. Information sufficient to identify the benefit request or claim involved, including any applicable dates of service, health care provider and claim amount, if applicable;

7.3.a.2. A statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; a request for the diagnosis code and treatment information shall not, in itself, be deemed a request to file a grievance for review of an adverse determination pursuant to W.Va. Code of St. R. § 114-96-1 et seq. or a request for external review;

7.3.a.3. The specific reasons or reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the issuer's standard, if any, that was used in denying the benefit request or claim;

7.3.a.4. Reference to the specific plan provisions on which the determination is based;

7.3.a.5. A description of any additional material or information necessary for the covered person to perfect the benefit request and an explanation of why the material or information is necessary;

7.3.a.6. A description of the issuer's grievance procedures established pursuant to W.Va. Code of St. R. § 114-96-1 et seq., including any time limits applicable to those procedures;

7.3.a.7. If the issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the final adverse determination, either the specific rule, guideline, protocol or other similar criterion or a statement that a specific rule, guideline, protocol or other similar criterion was relied upon to make the final adverse determination and that a copy of same will be provided free of charge to the covered person upon request;

7.3.a.8. An explanation of the scientific or clinical judgment for making any determination based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, applying the terms of the health benefit plan to the covered person's medical circumstances; and

7.3.a.9. A statement explaining the availability of and contact information for assistance through the Commissioner's office.

7.3.b. An issuer shall provide the notice required under this subsection 7.3 in a culturally and linguistically appropriate manner.
7.3.b.1. To be considered to meet the requirements of this subdivision, the issuer shall:
7.3.b.1.A. Provide oral language services, such as a telephone assistance hotline, that include answering questions in any applicable non-English language and providing assistance with filing benefit requests and claims and appeals in any applicable non-English language;

7.3.b.1.B. Provide, upon request, a notice in any applicable non-English language; and

7.3.b.1.C. Include in the English version of all notices, a statement prominently displayed in any applicable non-English language clearing indicating how to access the language services provided by the issuer.

7.3.b.2. For purposes of this subdivision, with respect to any United States county to which a notice is sent, a non-English language is an applicable non-English language if ten (10) percent or more of the population residing in the county is literate only in the same non-English language, as determined in published federal guidance.

7.3.c. If the adverse determination is a rescission, the issuer shall provide at least thirty calendar days' notice to a covered person before coverage may be rescinded, regardless of whether the rescission applies to an individual only, to an entire group, or to individuals in a group, in addition to any applicable disclosures required under subdivision 7.3.a:
7.3.c.1. Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;

7.3.c.2. An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;

7.3.c.3. Notice that the covered person may, prior to the date the advance notice of the proposed rescission ends, immediately file a grievance to request a review of the adverse determination to rescind coverage pursuant to W.Va. Code of St. R. § 114-96-1 et seq.;

7.3.c.4. A description of the issuer's grievance procedures established pursuant to W.Va. Code of St. R. § 114-96-1 et seq.; including any time limits applicable to those procedures; and

7.3.c.5. The date when the advance notice ends and the date back to which the coverage will be retroactively rescinded.

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