W. Va. Code R. § 114-58-3

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

Section 114-58-3 - Notice of Right to External Review

3.1. At the time the managed care plan sends written notice to the enrollee of an adverse determination, the managed care plan shall, if the enrollee has exhausted the managed care plan's internal review process, also notify the enrollee in writing of the enrollee's right to request an external review and shall include in the required notice:

a. The specific criteria and standards on which the adverse determination was based. Use of generalized terms such as "experimental procedure not covered," or "not medically necessary" is not sufficient to comply with this requirement;

b. A description of both the standard and expedited external review procedures;

c. The circumstances under which the enrollee or the enrollee's authorized representative may use either procedure;

d. The procedures for requesting an external review, including the time within which an external review must be requested;

e. The procedures giving the enrollee or the enrollee's authorized representative the opportunity to submit additional information;

f. The disclosure that the enrollee will not be responsible for the cost of the external review; and

g. All forms necessary to process an external review, including a form by which the enrollee or the enrollee's authorized representative may authorize the plan to disclose pertinent protected health information concerning the enrollee to the external review organization.

W. Va. Code R. § 114-58-3