W. Va. Code R. § 114-58-9

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

Section 114-58-9 - Minimum Qualifications for External Review Organizations

9.1. To be approved to conduct external reviews, an external review organization shall have and maintain written policies and procedures that govern all aspects of both the standard and expedited external review processes, which include, at a minimum:

a. A quality assurance program that:

1. Ensures that external reviews are conducted and all required notices are provided within the time frames specified in sections 5 and 6 of this rule;

2. Ensures the selection of qualified and impartial clinical peer reviewers to conduct external reviews on behalf of the external review organization and appropriate matching of clinical peers to specific cases;

3. Ensures the confidentiality of medical and treatment records, clinical review criteria, and personal information; and

4. Ensures that any person employed by or under the external review organization adheres to the requirements of this rule.

b. Procedures in place that:

1. Ensure appropriate systems, including a toll-free telephone number, are accessible twenty-four hours per day, seven days per week to receive a notice of selection for an external review and other information relating to an external review;

2. Ensure appropriate systems are available twenty-four hours per day, seven days per week to respond to a notice of selection for an external review; and

3. Ensure appropriate personnel are accessible not less than forty hours per week during normal business hours to discuss issues related to the external review.

c. Procedures to ensure the qualifications of reviewers. No party other than the external review organization shall control, directly or indirectly, the appointment of clinical peer reviewers to an external review. Each clinical peer assigned by an external review organization to conduct an external review shall:

1. Have expertise in the treatment of the medical condition of the enrollee and clinical experience in the past three years with the proposed health care service at issue;

2. Hold an unrestricted license by the state in the United States in which the clinical peer is licensed;

3. Not have been disciplined or sanctioned by a hospital or government entity based on the quality of care provided by the clinical peer; and

4. In the case of a physician, be certified by a nationally recognized medical specialty board in the area that is the subject of the review.

d. Procedures in place to prevent conflicts of interest. The external review organization shall maintain policies and procedures to ensure that neither the external review organization nor any clinical peer assigned to conduct the external review has a material professional, familial, or financial conflict of interest with:

1. The enrollee who is the subject of the review;

2. The managed care plan that is the subject of the review;

3. Any officer, director, or management employee of the managed care plan that is the subject of the review;

4. The health care provider or facility that would provide or has provided the health care service; or

5. The developer or manufacturer of the principal drug, device, procedure, or other therapy that is the subject of the review.

e. Procedures in place to ensure that no compensation or anything of value, other than payment for the fees and costs of the external review, shall be accepted, permitted, or provided by or to the external review organization, its employees or agents, or any clinical peer reviewer, that, directly or indirectly, encourages the affirmation or reversal of an adverse determination.

f. An agreement to maintain and provide to the commissioner the information set forth in section 11 of this rule.

g. A fee structure that is competitive and reasonable and does not exceed the maximum rates and maximum amounts permitted by the commissioner.

9.2. For the purpose of allowing health care providers to act as clinical peers in the conduct of external reviews, an affiliation with a hospital, an institution, an academic medical center, or a provider network does not solely constitute a conflict of interest sufficient to preclude that provider from acting as a clinical peer, as long as the affiliation is disclosed to the enrollee or the enrollee's authorized representative and the managed care plan and both parties agree that the clinical peer is acceptable to both parties.

W. Va. Code R. § 114-58-9