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 114-97-5 - Exhaustion of Internal Grievance Process

Universal Citation: 114 WV Code of State Rules 114-97-5

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

5.1. Except as provided in subsection 5.3 or if the exhaustion requirement is waived by the issuer, a request for external review pursuant to section 6, 7 or 8 may not be made until the covered person has exhausted the issuer's internal grievance process.

5.2. Except to the extent the covered person requested or agreed to a delay, he or she shall be deemed to have exhausted the issuer's internal grievance process for purposes of this section if he or she has not received a written decision from the issuer within thirty days after filing a grievance involving an adverse determination pursuant to the issuer's internal grievance process.

5.3. At the same time a covered person files a request for an expedited internal review of a grievance involving an adverse determination pursuant to W.Va. Code of St. R. §114-96, the covered person may file a request for an expedited external review of the adverse determination pursuant to either section 7 or 8, as appropriate.

5.3.a. Upon receipt of an assignment to conduct an expedited external review pursuant to section 7, the IRO shall determine whether the covered person will be required to complete the expedited review process set forth in W.Va. Code of St. R. §114-96.7 before it conducts the expedited external review.

5.3.b. Upon a determination made pursuant to subdivision 5.3.a that the covered person must first complete the expedited grievance review process set forth in W.Va. Code St. R. §114-96.7, the IRO shall immediately notify the covered person of this determination and that it will not proceed with the expedited external review set forth in section 7 until completion of the expedited grievance review process and the covered person's grievance at the completion of the expedited grievance review process remains unresolved.

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