W. Va. Code R. § 114-58-8

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

Section 114-58-8 - Approval of External Review Organizations

8.1. The commissioner shall approve external review organizations eligible to be assigned to conduct external reviews pursuant to W. Va. Code '33-25C-6 and this rule. An approval is effective for two years, unless the commissioner determines before expiration of the approval that the external review organization is not satisfying the minimum qualifications established under section 9 of this rule. The commissioner shall maintain a randomly organized roster of approved external review organizations.

8.2. An external review organization seeking approval to conduct external reviews shall submit an application on a form prescribed by the commissioner. The application shall include any documentation or information specified by the commissioner as necessary to determine if the external review organization meets the minimum qualifications established under section 9 of this rule. The external review organization will file with the application a schedule of fees and charges for approval by the commissioner.

8.3. To ensure continued compliance with this rule, the commissioner may:

a. Conduct periodic examinations and random audits of approved external review organizations. These examinations shall be at the expense of the external review organization.

b. Withdraw approval of the external review organization if the commissioner determines that an external review organization no longer satisfies the minimum requirements established under section 9 of this rule.

c. Investigate complaints by enrollees, managed care plans, and external reviewers regarding external reviews.

8.4. The commissioner, after reviewing the accreditation process and standards used by a national organization to accredit an external review organization, may determine that accreditation by the national organization satisfies the approval standards of the commissioner.

8.5. An approved external review organization may request termination of its approval by sending written notice to the commissioner at least sixty days prior to the effective date of the termination. No termination of an external review organization's approved status shall be effective until all pending external reviews assigned to the external review organization have been satisfactorily completed.

W. Va. Code R. § 114-58-8