W. Va. Code R. § 114-64-6

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

Section 114-64-6 - Concurrent Review and Denial of Benefits

6.1. In the event of a concurrent review for a claim for coverage of services for the prevention of, screening for, and treatment of behavioral health, mental health, and substance use disorders, the insurer or carrier must continue to cover the service until the insurer or carrier notifies the covered person of the determination of the claim.

6.2. An insurer or carrier shall provide the covered person with written notice of a denial when denying benefits for the treatment of behavioral health, mental health, and/or substance use disorders that explicitly provides the reason for the denial.

6.3. Unless denied for nonpayment of premium, a denial of reimbursement for services for the prevention of, screening for, or treatment of behavioral health, mental health, and/or substance use disorders by the insurer or carrier must include the following language:

6.3.1. A statement explaining that covered persons are protected under state and federal law, which provides that limitations placed on the access to behavioral health, mental health, and/or substance use disorder benefits may be no greater than any limitations placed on access to medical/surgical benefits for physical illness or injury;

6.3.2. A statement providing that the covered person may contact the Consumer Services Division of the West Virginia Offices of the Insurance Commissioner if the covered person believes his or her rights under state or federal law have been violated. The statement should provide up-to-date contact information for the Consumer Services Division, including the current mailing address, toll-free telephone number, email address and website; and

6.3.3. A statement specifying that the covered person is entitled, upon request to the insurer or carrier, to a copy of the medical necessity criteria for any behavioral health, mental health, and substance use disorder benefit.

W. Va. Code R. § 114-64-6