W. Va. Code R. § 114-96-7

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

Section 114-96-7 - Expedited Reviews of Grievances Involving an Adverse Determination

7.1. An issuer shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination.

7.2. In addition to subsection 7.1, an issuer shall provide expedited review of a grievance involving an adverse determination with respect to concurrent review urgent care requests involving an admission, availability of care, continued stay or health care service for a covered person who has received emergency services, but has not been discharged from a facility.

7.3. The procedures shall allow a covered person to request an expedited review under this section orally or in writing.

7.4. An issuer shall appoint an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed to review the adverse determination. The clinical peer or peers shall not have been involved in making the initial adverse determination.

7.5. In an expedited review, all necessary information, including the issuer's decision shall be transmitted between the issuer and the covered person by telephone, facsimile or the most expeditious method available.

7.6. An expedited review decision shall be made and the covered person shall be notified of the decision in accordance with subsection 7.8 as expeditiously as the covered person's medical condition requires, but in no event more than seventy-two hours after the receipt of the request for the expedited review. If the expedited review of a grievance involves an adverse determination with respect to a concurrent review urgent care request, the service shall be continued without liability to the covered person until the covered person has been notified of the determination.

7.7. For purposes of calculating the time periods within which a decision is required to be made under subsection 7.6, the time period within which the decision is required to be made shall begin on the date the request is filed with the issuer in accordance with the issuer's procedures established pursuant to section 4 for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.

7.8. Decision Notification.

7.8.a. A notification of a decision under this section shall, in a manner calculated to be understood by the covered person, set forth:

7.8.a.1. The titles and qualifying credentials of the person or persons participating in the expedited review process (the reviewers);

7.8.a.2. Information sufficient to identify the claim involved with respect to the grievance, including the date of service, the health care provider and, if applicable, the claim amount;

7.8.a.3. A statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning. For purposes of this paragraph, an issuer:

7.8.a.3.A. Shall upon request provide to the covered person, as soon as practicable, the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning, associated with any adverse determination; and

7.8.a.3.B. Shall not consider a request for the diagnosis code and treatment information, in itself, to be a request for external review pursuant to W.Va. Code of St. R. § 114-97-1et seq.;

7.8.a.4. A statement of the reviewers' understanding of the covered person's grievance;

7.8.a.5. The reviewers' decision in clear terms and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the issuer's position;

7.8.a.6. A reference to the evidence or documentation used as the basis for the decision; and

7.8.a.7. If the decision involves a final adverse determination, the notice shall provide:

7.8.a.7.A. The specific reasons or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description on the issuer's standard, if any, that was used in reaching the denial;

7.8.a.7.B. Reference to the specific plan provisions on which the determination is based;

7.8.a.7.C. A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;

7.8.a.7.D. If the issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol or other similar criterion or a statement that a specific rule, guideline, protocol or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol or other similar criterion will be provided free of charge to the covered person upon request;

7.8.a.7.E. If the final adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances, or a statement that an explanation will be provided to the covered person free of charge upon request;

7.8.a.7.F. If applicable, instructions for requesting:

7.8.a.7.F.1. A copy of the rule guideline, protocol or other similar criterion relied upon in making the adverse determination in accordance with subparagraph 7.8.a.7.D;

7.8.a.7.F.2. The written statement of the scientific or clinical rationale for the adverse determination in accordance with subparagraph 7.8.a.7.E;

7.8.a.7.F.3. A statement describing the procedures for obtaining an independent external review of the adverse determination pursuant to W.Va. Code of St. R. § 114-97-1 et seq.;

7.8.a.7.F.4. A statement indicating the covered person's right to bring a civil action in a court of competent jurisdiction;

7.8.a.7.F.5. The following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your state Insurance Commissioner."; and

7.8.a.7.F.6. A notice of the covered person's right to contact the Commissioner for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Commissioner's office.

7.8.b. An issuer shall provide the notice required under this section as set forth in subsection 5.9.

7.8.b.1. To be considered to meet the requirements of this subsection, the issuer shall:

7.8.b.1.A Provide oral language services, such as a telephone assistance hotline, that include answering questions in any applicable non-English language and providing assistance with filing benefit requests and claims and appeals in any applicable non-English language;

7.8.b.1.B. Provide, upon request, a notice in any applicable non-English language; and

7.8.b.1.C. Include in the English versions of all notices a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the carrier.

7.8.b.2. For purposes of this subdivision, with respect to any United States County to which a notice is sent, a non-English language is an applicable non-English language if ten percent or more of the population residing in the county is literate only in the same non-English language, as determined in published federal guidance.

7.8.c. An issuer may provide the notice required under this section orally, in writing or electronically. If notice of the adverse determination is provided orally, the issuer shall provide written or electronic notice of the adverse determination within three days following the oral notification.

W. Va. Code R. § 114-96-7