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 114-95-8 - Procedures for Expedited Utilization Review and Benefit Determinations
Universal Citation: 114 WV Code of State Rules 114-95-8
Current through Register Vol. XLI, No. 38, September 20, 2024
8.1. An issuer shall establish written procedures in accordance with this section for receiving benefit requests from covered persons and for making and notifying covered persons of expedited utilization review and benefit determinations with respect to urgent care requests and concurrent review urgent care requests.
8.1.a. Such procedures must include that, in the
case of a failure by a covered person to provide sufficient information, the issuer
shall notify the covered person either orally or, if requested by the covered
person, in writing of this failure and state what specific information is needed as
soon as possible, but in no event later than twenty-four hours after receipt of the
request, and the issuer shall provide the covered person a reasonable period of time
to submit the necessary information, taking into account the circumstances, but in
no event less than forty-eight hours after notifying the covered person of the
failure to submit sufficient information. The provisions of this subdivision 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.
8.1.b. For an urgent care request, unless the
covered person has failed to provide sufficient information for the issuer to
determine whether, or to what extent, the benefits requested are covered benefits or
payable under the issuer's health benefit plan, the issuer shall notify the covered
person of the issuer's determination with respect to the request, whether or not the
determination is an adverse determination, as soon as possible, taking into account
the medical condition of the covered person, but in no event later than seventy-two
hours after the receipt of the request by the issuer.
8.1.b.1. If the covered person has failed to
provide sufficient information for the issuer to determine whether, or to what
extent, the benefits requested are covered benefits or payable under the issuer's
health benefit plan, the issuer shall notify the covered person as soon as possible,
but in no event later than twenty-four (24) hours after receipt of the request,
either orally or, if requested by the covered person, in writing of this failure and
state what specific information is needed. The issuer shall provide the covered
person a reasonable period of time to submit the necessary information, taking into
account the circumstances, but in no event less than forty-eight (48) hours after
notifying the covered person or the covered person's authorized representative of
the failure to submit sufficient information.
8.1.b.2. The issuer shall notify the covered
person of its determination with respect to the urgent care request as soon as
possible, but in no event more than forty-eight hours after the earlier of:
8.1.b.2.A. The issuer's receipt of the requested
specified information; or
8.1.b.2.B. The
end of the period provided for the covered person to submit the requested specified
information.
8.1.b.3. If the
covered person fails to submit the information before the end of the period of the
extension, as specified in subparagraph 8.1.b.2.B, the issuer may deny the
certification of the requested benefit.
8.1.c. For concurrent review urgent care requests
involving a request by the covered person to extend the course of treatment beyond
the initial period of time or the number of treatments, if the request is made at
least twenty-four hours prior to the expiration of the prescribed period of time or
number of treatments, the issuer shall make a determination with respect to the
request and notify the covered person of the determination, whether it is an adverse
determination or not, as soon as possible, taking into account the covered person's
medical condition, but in no event more than twenty-four hours after the issuer's
receipt of the request.
8.1.d. For
purposes of calculating the time periods within which a determination is required to
be made under subsection 8.2, the time period within which the determination is
required to be made shall begin on the date the request is filed with 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.
8.2. Notice Requirements.
8.2.a. A notification of an adverse determination
under this section shall, in a manner calculated to be understood by the covered
person, set forth;
8.2.a.1. Information sufficient
to identify the benefit request or claim involved, including the date of service, if
applicable, the health care provider and the claim amount, if applicable;
8.2.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. For purposes of this paragraph, an issuer:
8.2.a.2.A. Shall provide to the covered person, as
soon as practicable, upon request, the diagnosis code and its corresponding meaning,
and the treatment code and its corresponding meaning, associated with any adverse
determination; and
8.2.a.2.B. May not
consider a request for the diagnosis code and treatment information, in itself, to
be 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;
8.2.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;
8.2.a.4.
Reference to the specific plan provisions on which the determination is
based;
8.2.a.5. A description of any
additional material or information necessary for the covered person to complete the
request, including an explanation of why the material or information is necessary to
complete the request;
8.2.a.6. A
description of the issuer's internal review and expedited review procedures
established pursuant to W.Va. Code of St. R. §
114-96-1
et
seq., including any time limits applicable to those procedures;
8.2.a.7. If the issuer relied upon an internal
rule, guideline, protocol or other similar criterion to make the 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 adverse determination and that a copy of the
rule, guideline, protocol or other similar criterion will be provided free of charge
to the covered person upon request;
8.2.a.8. If the adverse determination is based on
a medical necessity or experimental or investigational treatment or similar
exclusion or limit, either an explanation of the scientific or clinical judgment for
making the determination, applying the terms of the health benefit plan to the
covered person's medical circumstances or a statement that an explanation will be
provided to the covered person free of charge upon request;
8.2.a.9. If applicable, instructions for
requesting:
8.2.a.9.A. A copy of the rule,
guideline, protocol or other similar criterion relied upon in making the adverse
determination in accordance with paragraph 8.2.a.7; or
8.2.a.9.B. The written statement of the scientific
or clinical rationale for the adverse determination in accordance with paragraph
8.2.a.8; and
8.2.a.10. A
statement explaining the availability of and the right of the covered person, as
appropriate, to contact the Commissioner's office at any time for assistance or,
upon completion of the issuer's grievance procedures process as provided under W.Va.
Code of St. R. §
114-96-1
et
seq., to file a civil suit in a court of competent jurisdiction. The
statement shall include contact information for the Commissioner's
office.
8.2.b. An issuer shall
provide the notice required under this section in a culturally and linguistically
appropriate manner in accordance with subdivision 7.3.b.
8.2.c. If the adverse determination is a
rescission, the issuer shall provide, in addition to any applicable disclosures
required under subdivision 8.2.a, the disclosures set forth in subdivision
7.3.c:
8.2.d.. An issuer may provide the
notice required under this section orally, in writing or electronically. If notice
of the adverse determination is provided orally, the issuer shall provide written or
electronic notice of the adverse determination within three days following the oral
notification.
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