W. Va. Code R. § 114-96-6

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

Section 114-96-6 - Standard Reviews of Grievances Not Involving an Adverse Determination

6.1. An issuer shall establish written procedures for a standard review of a grievance that does not involve an adverse determination.

6.2. The procedures shall permit a covered person to file a grievance that does not involve an adverse determination with the issuer under this section.

6.2.a. A covered person does not have the right to attend, or to have a representative in attendance at the standard review, but the covered person is entitled to submit written material for the person or persons designated by the carrier pursuant to subsection 6.3 to consider when conducting the review.

6.2.b.. The issuer shall make the provisions of subdivision 6.2.a known to the covered person within three working days after the date of receiving the grievance.

6.3. Upon receipt of the grievance, an issuer shall designate a person or persons to conduct the standard review of the grievance.

6.3.a. The issuer may not designate the same person or persons to conduct the standard review of the grievance that denied the claim or handled the matter that is the subject of the grievance.

6.3.b. The issuer shall provide the covered person with the name, address and telephone number of a person designated to coordinate the standard review on behalf of the issuer.

6.4. The issuer shall notify in writing the covered person of the decision within twenty working days after the date of receipt of the request for a standard review of a grievance filed pursuant to subsection 6.2.

6.4.a. Subject to subdivision 6.4.b, if, due to circumstances beyond the issuer's control, the issuer cannot make a decision and notify the covered person pursuant to subsection 6.4 within twenty working days, the issuer may take up to an additional ten working days to issue a written decision.

6.4.b. An issuer may extend the time for making and notifying the covered person in accordance with subdivision 6.4.a, if, on or before the twentieth working day after the date of receiving the request for a standard review of a grievance, the issuer provides written notice to the covered person of the extension and the reasons for the delay.

6.5. The written decision issued pursuant to subsection 6.4 shall contain:

6.5.a. The titles and qualifying credentials of the person or persons participating in the standard review process (the reviewers);

6.5.b. A statement of the reviewers' understanding of the covered person's grievance;

6.5.c. The reviewer's decision in clear terms and the contract basis in sufficient detail for the covered person to respond further to the issuer's position;

6.5.d. A reference to the evidence or documentation used as the basis for the decision; and

6.5.e. Notice of the covered person's right, at any time to contact the Commissioner's office, including the telephone number and address of the Commissioner's office.

W. Va. Code R. § 114-96-6