W. Va. Code R. § 114-97-14

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

Section 114-97-14 - Disclosure Requirements

14.1. Each issuer shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons.

14.2. The description required under subsection 14.1 shall be in a format prescribed by the Commissioner that informs the covered person of his or her right to file a request for an external review of an adverse determination or final adverse determination with the Commissioner; explains that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness; and that includes the telephone number and address of the Commissioner.

14.3. In addition to subsection 14.2, the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

W. Va. Code R. § 114-97-14