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 114-97-10 - Approval of IROs

Universal Citation: 114 WV Code of State Rules 114-97-10

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

10.1. The Commissioner shall approve IROs eligible to be assigned to conduct external reviews under this rule.

10.2. In order to be eligible for approval by the Commissioner under this section to conduct external reviews under this rule, an IRO:

10.2.a. Except as otherwise provided in this section, shall be accredited by a nationally recognized private accrediting entity that the Commissioner has determined has IRO accreditation standards that are equivalent to or exceed the minimum qualifications for IROs established under section 11; and

10.2.b. Shall submit an application for approval in accordance with subsection 10.4.

10.3. The Commissioner shall develop an application form for initially approving and for re-approving IROs to conduct external reviews.

10.4. Any IRO wishing to be approved to conduct external reviews under this rule shall submit the application and include with the form all documentation and information necessary for the Commissioner to determine if the IRO satisfies the minimum qualifications established under section 11.

10.4.a Subject to subdivision 10.4.b, an IRO is eligible for approval under this section only if it is accredited by a nationally recognized private accrediting entity that Commissioner has determined has IRO accreditation standards that are equivalent to or exceed the minimum qualifications for IROs under section 11.

10.4.b. The Commissioner may approve IROs that are not accredited by a nationally recognized private accrediting entity if there are no acceptable nationally recognized private accrediting entities providing IRO accreditation.

10.5. An approval is effective for two years, unless the Commissioner determines before its expiration that the IRO is not satisfying the minimum qualifications established under section 11. Whenever the Commissioner determines that an IRO has lost its accreditation or no longer satisfies the minimum requirements established under section 11, the Commissioner shall terminate the approval of the IRO and remove it from the list maintained pursuant to subsection 10.6.

10.6. The Commissioner shall maintain and periodically update a list of approved IROs.

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