W. Va. Code R. § 114-96-4

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

Section 114-96-4 - Grievance Review Procedures

4.1. Whenever an issuer fails to adhere to the requirements of section 5 or section 7 with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the provisions of this rule and may file a request for external review in accordance with the procedures outlined in W.Va. Code of St. R. § 114-97-1et seq.

4.1.a. Notwithstanding subsection 4.1, the provisions of section 5 shall not be deemed exhausted based on a de minimis violation that does not cause, and is not likely to cause, prejudice or harm to the covered person as long as the issuer demonstrates that the violation was for good cause or due to matters beyond the control of the issuer and that the violation occurred in the context of an ongoing, good faith exchange of information between the issuer and the covered person.

4.1.a.1. The exception provided in subdivision 4.1 .a does not apply if the violation is part of a pattern or practice of violations by the issuer.

4.1.a.2. An issuer shall, within ten days of receiving a written request from a covered person, provide a written explanation of the basis, if any, for asserting that the alleged violation of section 5 or 7 does not entitle the covered person to claim exhaustion.

4.1.b. If an independent review organization rejects the grievance involving an adverse determination for immediate review on the basis that the issuer met the requirements of the exception provided in subdivision 4.1.a., the covered person has the right to resubmit and pursue a review of the grievance under this rule.

4.1.b.1. In this case, within a reasonable time but not exceeding ten days after the independent review organization rejects the grievance involving an adverse determination for immediate review, the issuer shall provide to the covered person notice of the opportunity to resubmit and, as appropriate, pursue a review of the grievance under this rule.

4.1.b.2. For purposes of calculating the time period for re-filing the benefit request or claim under this paragraph, the time period shall begin to run upon the covered person's receipt of the notice of opportunity to resubmit.

4.2. An issuer shall file a copy of the procedures required under subsection 4.1, including all forms used to process requests made pursuant to section 5, 6 and 7, with the Commissioner. Any subsequent material modifications to the documents also shall be filed. The Commissioner may disapprove a filing received in accordance with this subsection that fails to comply with this rule.

4.3. In addition to subsection 4.2, an issuer shall file annually with the Commissioner, as part of its annual report required by section 3, a certificate of compliance stating that the issuer has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this rule.

4.4. A description of the grievance procedures required under this section shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage provided to covered persons.

4.5. The grievance procedure documents shall include a statement of a covered person's right to contact the Commissioner's office for assistance at any time. The statement shall include the telephone number and address for the Commissioner's office.

W. Va. Code R. § 114-96-4