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 114-97-3 - Notice of Right to External Review
Universal Citation: 114 WV Code of State Rules 114-97-3
Current through Register Vol. XLI, No. 38, September 20, 2024
3.1. An issuer shall notify the covered person in writing of the covered person's right to request an external review. Such a written notice from an issuer of an adverse determination upon completion of the issuer's utilization review process or of a final adverse determination shall include:
3.1.a. Notice of the
covered person's right to request an external review to be conducted pursuant to
section 6, 7 or 8;
3.1.b. The following
or substantially equivalent language: "We have denied your request for the provision
of or payment for a health care service or course of treatment. You may have the
right to have our decision reviewed by health care professionals who have no
association with us if our decision involved making a judgment as to the medical
necessity, appropriateness, health care setting, level of care or effectiveness of
the health care service or treatment you requested by submitting a request for
external review to the WV Offices of the Insurance Commissioner, P.O. Box 50540,
Charleston, WV 25305."
3.1.c. The
description provided pursuant to section 14 of both the standard and expedited
external review procedures, highlighting the provisions in the external review
procedures that give the covered person the opportunity to submit additional
information and including any forms used to process an external review
request.
3.1.d. A form approved by the
Commissioner by which the covered person authorizes the issuer and the covered
person's treating health care provider to disclose protected health information,
including medical records, concerning the covered person that are pertinent to the
external review.
3.1.e. For a notice
related to an adverse determination, a statement informing the covered person that:
3.1.e.1. If he or she has a medical condition
where the time-frame for expedited review of a grievance under the issuer's internal
grievance process would seriously jeopardize his or her life, health or ability to
regain maximum function, he or she may file with the Commissioner, simultaneously
with a request for expedited review under the issuer's internal grievance process, a
request for expedited external review to be conducted pursuant to section 7 or, in
cases involving denials based on the issuer's determination that the treatment or
service is experimental or investigational where the covered person's treating
physician certifies in writing that the recommended or requested service or
treatment would be significantly less effective if not promptly initiated, pursuant
to section 8; and
3.1.e.2. The covered
person may file a grievance under the issuer's internal grievance process, but if
the issuer has not issued a written decision to the covered person within thirty
days, he or she shall, except to the extent he or she requested or agreed to a
delay, be considered to have exhausted the issuer's internal grievance process for
the purposes of filing a request for external review pursuant to section
5.
3.1.f. For a notice
related to a final adverse determination, a statement informing the covered person
that:
3.1.f.1. If the covered person has a medical
condition where the timeframe for completion of a standard external review pursuant
to section 6 would seriously jeopardize the covered person's life or health or
ability to regain maximum function, the covered person may file a request for an
expedited external review pursuant to section 7; or
3.1.f.2. If the final adverse determination
concerns:
3.1.f.2.A. An admission, availability of
care, continued stay or health care service for which the covered person received
emergency services, but has not been discharged from a facility, the covered person
may request an expedited external review pursuant to section 7; or
3.1.f.2.B. A denial of coverage based on a
determination that the recommended or requested health care service or treatment is
experimental or investigational, the covered person may file a request for a
standard external review to be conducted pursuant to section 8 or, if the covered
person's treating physician certifies in writing that the recommended or requested
health care service or treatment that is the subject of the request would be
significantly less effective if not promptly initiated, the covered person may
request an expedited external review to be conducted under subsection 8.2.
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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