W. Va. Code R. § 114-95-5

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

Section 114-95-5 - Scope and Content of Utilization Review Program

5.1. An issuer shall implement a written utilization review program that describes all review activities and procedures, both delegated and non-delegated, for:

5.1.a. The filing of benefit requests;

5.1.b. The notification of utilization review and benefit determinations; and

5.1.c. The review of adverse determinations in accordance with W.Va. Code of St. R. § 114-96-1et seq., "Health Plan Issuer Internal Grievance Procedure".

5.2. The program document shall describe the following:

5.2.a. Procedures to evaluate the medical necessity, appropriateness, efficacy or efficiency of health care services;

5.2.b. Data sources and clinical review criteria used in decision-making;

5.2.c. Mechanisms to ensure consistent application of clinical review criteria and compatible decisions;

5.2.d. Data collection processes and analytical methods used in assessing utilization of health care services;

5.2.e. Provisions for assuring confidentiality of clinical and proprietary information;

5.2.f. The organizational structure (e.g. utilization review committee, quality assurance or other committee) that periodically assesses utilization review activities and reports to the issuer's governing body; and

5.2.g. The staff position functionally responsible for day-to-day program management.

W. Va. Code R. § 114-95-5