7.8. Decision Notification.
7.8.a. A notification of a decision under this
section shall, in a manner calculated to be understood by the covered person, set
forth:
7.8.a.1. The titles and qualifying
credentials of the person or persons participating in the expedited review process
(the reviewers);
7.8.a.2. Information
sufficient to identify the claim involved with respect to the grievance, including
the date of service, the health care provider and, if applicable, the claim
amount;
7.8.a.3. 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:
7.8.a.3.A. Shall upon
request provide to the covered person, as soon as practicable, the diagnosis code
and its corresponding meaning and the treatment code and its corresponding meaning,
associated with any adverse determination; and
7.8.a.3.B. Shall not consider a request for the
diagnosis code and treatment information, in itself, to be a request for external
review pursuant to W.Va. Code of St. R. §
114-97-1
et
seq.;
7.8.a.4. A
statement of the reviewers' understanding of the covered person's
grievance;
7.8.a.5. The reviewers'
decision in clear terms and the contract basis or medical rationale in sufficient
detail for the covered person to respond further to the issuer's position;
7.8.a.6. A reference to the evidence or
documentation used as the basis for the decision; and
7.8.a.7. If the decision involves a final adverse
determination, the notice shall provide:
7.8.a.7.A. The specific reasons or reasons for the
final adverse determination, including the denial code and its corresponding
meaning, as well as a description on the issuer's standard, if any, that was used in
reaching the denial;
7.8.a.7.B.
Reference to the specific plan provisions on which the determination is
based;
7.8.a.7.C. 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;
7.8.a.7.D. 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;
7.8.a.7.E. If the final 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;
7.8.a.7.F. If applicable, instructions for
requesting:
7.8.a.7.F.1. A copy of the rule
guideline, protocol or other similar criterion relied upon in making the adverse
determination in accordance with subparagraph 7.8.a.7.D;
7.8.a.7.F.2. The written statement of the
scientific or clinical rationale for the adverse determination in accordance with
subparagraph 7.8.a.7.E;
7.8.a.7.F.3. A
statement describing the procedures for obtaining an independent external review of
the adverse determination pursuant to W.Va. Code of St. R. §
114-97-1 et seq.;
7.8.a.7.F.4. A statement indicating the covered
person's right to bring a civil action in a court of competent
jurisdiction;
7.8.a.7.F.5. The following
statement: "You and your plan may have other voluntary alternative dispute
resolution options, such as mediation. One way to find out what may be available is
to contact your state Insurance Commissioner."; and
7.8.a.7.F.6. A notice of the covered person's
right to contact the Commissioner for assistance with respect to any claim,
grievance or appeal at any time, including the telephone number and address of the
Commissioner's office.
7.8.b. An issuer shall provide the notice required
under this section as set forth in subsection 5.9.
7.8.b.1. To be considered to meet the requirements
of this subsection, the issuer shall:
7.8.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;
7.8.b.1.B. Provide, upon
request, a notice in any applicable non-English language; and
7.8.b.1.C. Include in the English versions of all
notices a statement prominently displayed in any applicable non-English language
clearly indicating how to access the language services provided by the
carrier.
7.8.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 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.
7.8.c. 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.
