West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-96 - Health Plan Issuer Internal Grievance Procedure
Section 114-96-2 - Definitions

Universal Citation: 114 WV Code of State Rules 114-96-2

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

2.1. "Adverse determination" means a determination by an issuer or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the issuer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and the requested service or payment for the service is therefore denied, reduced or terminated.

2.2. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.

2.3. "Authorized representative" means:

2.3.a. A person to whom a covered person has given express written consent to represent the covered person in an internal review;

2.3.b. A person authorized by law to provide substituted consent for a covered person;

2.3.c. In a situation in which a covered person is unable to provide consent, a family member of the covered person or the covered person's treating health care professional;

2.3.d. A health care professional when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional; or

2.3.e. In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.

2.4. "Case management means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.

2.5. "Certification" means a determination by an issuer or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit under the issuer's health benefit plan has been reviewed and, based on the information provided, satisfies the issuer's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.

2.6. "Clinical peer" means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty that typically manages the medical condition, procedure or treatment under review.

2.7. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the issuer to determine the medical necessity and appropriateness of health care services.

2.8. "Commissioner" means the West Virginia Insurance Commissioner.

2.9. "Concurrent review" means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting.

2.10. "Covered benefits" or "benefits" means those health care services to which a covered person is legally entitled under the terms of a health benefit plan.

2.11. "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan; whenever this rule provides for action by or notice to a covered person, it shall be deemed to include action by or notice to such covered person's authorized representative.

2.12. "Discharge planning" means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.

2.13. "Emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

2.14. "Emergency services" means with respect to an emergency medical condition:

2.14.a. A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

2.14.b. Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities available at a hospital, to stabilize a patient.

2.15. "Facility" means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

2.16. "Final adverse determination" means an adverse determination that has been upheld by the issuer at the completion of the internal grievance procedures or an adverse determination with respect to which the internal grievance procedures have been exhausted.

2.17. "Grievance" means a written complaint or, if the complaint involves an urgent care request submitted by or on behalf of a covered person, an oral complaint, regarding:

2.17.a. Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

2.17.b. Claims payment, handling or reimbursement for health care services; or

2.17.c. Matters pertaining to the contractual relationship between a covered person and an issuer.

2.18. "Health benefit plan" means a policy, contract, certificate or agreement entered into, offered or issued by an issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including short term and catastrophic health insurance policies and a policy that pays on a cost-incurred basis, but excluding the excepted benefits defined in 42 U.S.C. § 300gg-91 and as otherwise specifically excepted in this rule.

2.18.a. "Health benefit plan" does not include:
2.18.a.1. Coverage only for accident, or disability income insurance or any combination thereof;

2.18.a.2. Coverage issued as a supplement to liability insurance;

2.18.a.3. Liability insurance, including general liability insurance and automobile liability insurance;

2.18.a.4. Workers' compensation or similar insurance;

2.18.a.5. Automobile medical payment insurance;

2.18.a.6. Credit-only insurance;

2.18.a.7. Coverage for on-site medical clinics; and

2.18.a.8. Other similar insurance coverage specified in federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits.

2.18.b. "Health benefit plan" does not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
2.18.b.1. Limited scope dental or vision benefits;

2.18.b.2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or

2.18.b.3. Other similar, limited benefits specified in federal regulations issued pursuant to Pub. L. No. 104-191.

2.18.c. "Health benefit plan" does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:
2.18.c.1. Coverage only for a specified disease or illness; or

2.18.c.2. Hospital indemnity or other fixed indemnity insurance.

2.18.d. "Health benefit plan" does not include the following if offered as a separate policy, certificate or contract of insurance:
2.18.d.1. Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;

2.18.d.2. Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)); or

2.18.d.3. Similar supplemental coverage provided to coverage under a group health plan.

2.19. "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with West Virginia law.

2.20. "Health care provider" or "provider" means a health care professional or a facility.

2.21. "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.

2.22. "Issuer" means an entity required to be licensed under the insurance laws and regulations of West Virginia that contracts, or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including an accident and sickness insurance company, a health maintenance organization, a nonprofit hospital or health service corporation, fraternal benefit society, or any other entity providing a health benefit plan.

2.23. "Managed care plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the issuer.

2.24. "Network" means the group of participating providers providing services to a managed care plan.

2.25. "Participating provider' means a provider who, under a contract with the issuer or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the issuer.

2.26. "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.

2.27. "Prospective review" means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with an issuer's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision.

2.28. "Rescission" means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. "Rescission" does not include a cancellation or discontinuance of coverage under a health benefit plan if:

2.28.a. The cancellation or discontinuance of coverage has only a prospective effect; or

2.28.b. The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

2.29. "Retrospective review" means any review of a request for a benefit that is not a prospective review request. "Retrospective review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.

2.30. "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the medical necessity and appropriateness of the initial proposed health care service.

2.31. "Stabilized" means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility or, with respect to a pregnant woman, the woman has delivered, including the placenta.

2.32. "Urgent care request" means a request for a health care service or course of treatment with respect to which the time periods for making a non-urgent care request determination:

2.32.a. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or

2.32.b. In the opinion of an attending health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.

2.32.c. Except as provided in subdivision 2.32.d, in determining whether a request is be treated as an urgent care request, an individual acting on behalf of the issuer shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

2.32.d. Any request that an attending health care professional, with knowledge of the covered person's medical condition, determines is an urgent care request within the meaning of this subsection shall be treated as an urgent care request.

2.33. "Utilization review" means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities.

2.34. "Utilization review organization" means an entity that conducts utilization review, other than an issuer performing utilization review for its own health benefit plans.

Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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