West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-97 - External Review of Adverse Health Insurance Determinations
Section 114-97-1 - General
Current through Register Vol. XLI, No. 38, September 20, 2024
1.1. Scope. -- The purpose of this rule is to provide a process under which persons covered by health insurance have the opportunity for independent reviews of adverse coverage determinations by issuers. This rule is based on the National Association of Insurance Commissioners' "Uniform Health Carrier External Review Model Act" (Model 76), as amended in 2010. This rule should be read in conjunction with series 95 ("Utilization Review") and 96 ("Health Plan Issuers Internal Grievance Process") of this title. Although review of adverse determinations normally proceeds first through the issuer's internal grievance procedure before it is assigned to an independent review organization, the rule permits the internal review process to be circumvented when the time necessary to conduct it could adversely affect the covered person's health.
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.
