W. Va. Code R. § 114-58-10

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-58-10 - External Review Organization Reporting Requirements

10.1. An external review organization shall maintain records in the aggregate and by managed care plan on all standard and expedited external reviews it conducts pursuant to assignment by the commissioner during each calendar year. The external review organization shall retain the records required by this subsection for at least three years.

10.2. Each external review organization conducting an external review pursuant to assignment by the commissioner shall, by the 31st day of March of each year for the preceding calendar year, submit a report on a form prescribed by the commissioner. The report required by this subsection shall include in the aggregate, for each managed care plan, and for West Virginia external reviews only, the following information:

a. The total number of requests for external review;

b. The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination and the number resolved reversing the adverse determination;

c. The average length of time for standard external reviews and for expedited external reviews;

d. A summary of the types of coverages or cases for which an external reviews were sought and the types of health care plans involved in the external reviews;

e. The number of external reviews that were terminated at the request of the managed care plan as the result of a reconsideration by the managed care plan, except those external reviews terminated because the enrollee and/or the treating provider presented as part of the external review information that had not been provided to the plan prior to the external review; and

f. Any other information the commissioner may request or require.

W. Va. Code R. § 114-58-10