W. Va. Code R. § 114-97-12

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

Section 114-97-12 - External Review Reporting Requirements

12.1. An IRO assigned pursuant to section 6, 7 or 8 to conduct an external review shall maintain written records in the aggregate by state and by issuer on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the Commissioner, as required under subdivision 12.1.a.

12.1.a. Each IRO required to maintain written records on all requests for external review pursuant to this subsection for which it was assigned to conduct an external review shall submit to the Commissioner, upon request, a report in the format specified by the Commissioner.

12.1.b. The report shall include in the aggregate by state, and for each issuer:

12.1.b.1. The total number of requests for external review;

12.1.b.2. The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;

12.1.b.3. The average length of time for resolution;

12.1.b.4. A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner;

12.1.b.5. The number of external reviews pursuant to subsection 8.8 that were terminated as the result of a reconsideration by the issuer of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative; and

12.1.b.6. Any other information the Commissioner may request or require.

12.1.c. The IRO shall retain the written records required pursuant to this subsection for at least three years.

12.2. Each issuer shall maintain written records in the aggregate, by state and for each type of health benefit plan offered by the issuer on all requests for external review that the issuer receives notice of from the Commissioner pursuant to this rule.

12.2.a. Each issuer required to maintain written records on all requests for external review pursuant to this subsection shall submit to the Commissioner, upon request, a report in the format specified by the Commissioner.

12.2.b. The report shall include in the aggregate, by state, and by type of health benefit plan:

12.2.b.1. The total number of requests for external review;

12.2.b.2. From the total number of requests for external review reported under paragraph 12.2.b.1, the number of requests determined eligible for a full external review; and

12.2.b.3. Any other information the Commissioner may request or write.

12.2.c. The issuer shall retain the written records required pursuant to this subsection for the lesser of the current calendar year plus five calendar years or five years from the closing date of the period of review for the most recent examination by the Commissioner.

W. Va. Code R. § 114-97-12