W. Va. Code R. § 114-58-4

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

Section 114-58-4 - Request for External Review

4.1. An enrollee or the enrollee's authorized representative may make a request for external review of an adverse determination only where the denial, reduction, modification or termination of payment for health care services or course of health care services would result in payment of at least one thousand dollars if the health care services were paid for by the enrollee. The enrollee must submit documentation from his or her provider verifying that the cost of the health care services would result in payment of at least one thousand dollars if paid for by the enrollee.

4.2. Except for a request for an expedited external review made pursuant to section 6, all requests for external review shall be made in writing to the commissioner and the managed care plan. A request for an expedited external review may be made by electronic means to the commissioner and the managed care plan, followed by written confirmation not later than three business days after the electronic request is made.

4.3. Requests for external review shall be made:

a. Within sixty calendar days after the managed care plan has exceeded the time periods for grievances provided in W. Va. Code '33-25A-12, without reaching a decision; or

b. Within sixty calendar days after receiving written notice of an adverse determination by the managed care plan.

4.4. A request for external review of an adverse determination shall not be made until the enrollee has exhausted the managed care plan's internal grievance process. An enrollee shall be considered to have exhausted the managed care plan's internal grievance process if:

a. The internal grievance process has been completed timely and the enrollee has received an adverse determination; or

b. Except to the extent the enrollee or the enrollee's authorized representative requested or caused a delay, the managed care plan has exceeded the time periods for grievances provided in W. Va. Code '33-25A-12, without reaching a decision.

4.5. External review shall not be made until the enrollee has provided to the managed care plan and the commissioner an authorization allowing the plan to disclose pertinent protected health information concerning the enrollee to the external review organization.

W. Va. Code R. § 114-58-4