W. Va. Code R. § 114-58-6

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

Section 114-58-6 - Expedited External Reviews

6.1. Except for retrospective adverse determinations, an enrollee or an enrollee's authorized representative may request an expedited external review of an adverse determination in circumstances where failure of the enrollee to immediately receive the health care service could result in placing the health of the enrollee or the health of the enrollee's unborn child in serious jeopardy, cause serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Requests for expedited external review shall be made to the commissioner and the managed care plan.

6.2. A request for an expedited external review must include a certification from the enrollee's health care provider that the enrollee's medical condition meets the criteria set forth in subsection 6.1. Such certification shall include a clinical explanation of how the enrollee's condition meets the criteria.

6.3. Within two business days of receiving a request for an expedited external review, the commissioner shall determine if the criteria set forth in subsection 5.1 have been met, and shall send notification to the enrollee and the managed care plan of the following:

a. If the criteria for the preliminary determination set forth in subsection 5.1 have not been met, that the request is denied; or

b. If the criteria for the preliminary determination set forth in subsection 5.1 have been met and the request is complete, that the request has been certified for expedited external review. If certified by the commissioner, the commissioner shall randomly select an external review organization that does not have a conflict of interest and include in the notice the name, address, and telephone number of the external review organization to which the expedited review has been assigned.

6.4. If the commissioner cannot make the preliminary determination required by subsection 5.1 because the request for external review is incomplete, the notice shall so state and shall describe the information or materials needed to make the request complete.

6.5. The notification required by subsection 6.3 shall be provided by telephone, facsimile, electronic means, or any other expeditious method, followed by written confirmation no later than the next business day.

6.6. The standard of review in an expedited external review shall be as set forth in subsection 5.6.

6.7. Expedited external reviews shall be conducted pursuant to subsection 5.7.

6.8. Within two business days from the date the managed care plan receives the initial notice from the commissioner that the request has been certified for external review, the managed care plan shall deliver to the assigned external review organization all documents and information described in subsection 5.8. The commissioner may order the managed care plan to deliver the required documentation and information to the external review organization in one business day if the enrollee's health condition so warrants. The documents and information shall be transmitted by facsimile, electronic means or some other available expeditious method.

a. The failure of the managed care plan to provide the information and documents set forth in this subsection within the stated time frame may result in the termination of the expedited external review and a decision to reverse the adverse determination.

b. At the same time the information required by this subsection is delivered to the external review organization, the managed care plan shall also provide to the enrollee by telephone, facsimile, or electronic means the index of documents submitted. The enrollee or the enrollee's authorized representative may submit additional information to the external review organization within two business days from the date the enrollee receives the index from the managed care plan.

c. Upon delivery of the required information and documentation to the external review organization, the managed care plan shall also provide to the commissioner written verification of its compliance with this subsection.

6.9. The managed care plan, the enrollee, or the enrollee's health care provider shall provide any additional information the external review organization requests to complete the review. The additional information shall be provided to the external review organization within two business days of the request unless such time is extended by the commissioner for good cause shown. The external review organization shall make the request for additional information by telephone, facsimile, or by electronic means, followed by written confirmation no later than the next business day. If the requested additional information is not provided within the time specified, the external review organization shall proceed with its review without the information.

a. At the same time any additional information is submitted by the enrollee or the enrollee's health care provider to the external review organization, the enrollee or the enrollee's health care provider shall also submit a copy of the information to the managed care plan.

b. At the same time any additional information is submitted by the managed care plan to the external review organization, the managed care plan shall also submit a copy of the information to the enrollee or the enrollee's authorized representative.

6.10. In making its decision, an external review organization shall consider safety, efficacy, appropriateness, and cost effectiveness. It shall take into account all of the information described in subsections 5.8 and 5.13, as well as all other information submitted by the managed care plan, the enrollee and the enrollee's health care provider.

6.11. Nothing in this rule shall be construed to require the external review organization to utilize medical professionals or criteria in making decisions in expedited external reviews regarding coverage for care by religious nonmedical providers.

6.12. As soon as possible, but not more than seven calendar days after the date the request for expedited external review is received by the commissioner, the assigned external review organization shall notify the enrollee, the managed care plan, and the commissioner of its decision to uphold or reverse the managed care plan's adverse determination. The notification shall be made by telephone, facsimile, or electronic means, followed by written confirmation no later than the next business day. The written confirmation of the external review organization's decision shall include the following information:

a. The information required by subsection 5.16 of this rule; and

b. An explanation that the external review decision is the final appeal available to the enrollee under state insurance law.

6.13. The managed care plan may elect at any time during the expedited external review to cover the proposed health care service and request termination of the expedited review. The managed care plan shall notify the enrollee, the external review organization and the commissioner by telephone, facsimile, or electronic means, of its election to provide coverage, followed by written confirmation. Upon receipt of the notice from the managed care plan, the external review organization shall terminate the external review.

6.14. If the external review organization reverses the adverse determination, the managed care plan shall immediately notify the enrollee that it will provide coverage for the proposed health care services.

6.15. An enrollee shall not be required to pay for any part of the cost of the expedited review. All costs and fees associated with the expedited external review shall be borne by the managed care plan.

W. Va. Code R. § 114-58-6