W. Va. Code R. § 114-97-3

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

Section 114-97-3 - Notice of Right to External Review

3.1. An issuer shall notify the covered person in writing of the covered person's right to request an external review. Such a written notice from an issuer of an adverse determination upon completion of the issuer's utilization review process or of a final adverse determination shall include:

3.1.a. Notice of the covered person's right to request an external review to be conducted pursuant to section 6, 7 or 8;

3.1.b. The following or substantially equivalent language: "We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the WV Offices of the Insurance Commissioner, P.O. Box 50540, Charleston, WV 25305."

3.1.c. The description provided pursuant to section 14 of both the standard and expedited external review procedures, highlighting the provisions in the external review procedures that give the covered person the opportunity to submit additional information and including any forms used to process an external review request.

3.1.d. A form approved by the Commissioner by which the covered person authorizes the issuer and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.

3.1.e. For a notice related to an adverse determination, a statement informing the covered person that:

3.1.e.1. If he or she has a medical condition where the time-frame for expedited review of a grievance under the issuer's internal grievance process would seriously jeopardize his or her life, health or ability to regain maximum function, he or she may file with the Commissioner, simultaneously with a request for expedited review under the issuer's internal grievance process, a request for expedited external review to be conducted pursuant to section 7 or, in cases involving denials based on the issuer's determination that the treatment or service is experimental or investigational where the covered person's treating physician certifies in writing that the recommended or requested service or treatment would be significantly less effective if not promptly initiated, pursuant to section 8; and

3.1.e.2. The covered person may file a grievance under the issuer's internal grievance process, but if the issuer has not issued a written decision to the covered person within thirty days, he or she shall, except to the extent he or she requested or agreed to a delay, be considered to have exhausted the issuer's internal grievance process for the purposes of filing a request for external review pursuant to section 5.

3.1.f. For a notice related to a final adverse determination, a statement informing the covered person that:

3.1.f.1. If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to section 6 would seriously jeopardize the covered person's life or health or ability to regain maximum function, the covered person may file a request for an expedited external review pursuant to section 7; or

3.1.f.2. If the final adverse determination concerns:

3.1.f.2.A. An admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person may request an expedited external review pursuant to section 7; or

3.1.f.2.B. A denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person may file a request for a standard external review to be conducted pursuant to section 8 or, if the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person may request an expedited external review to be conducted under subsection 8.2.

W. Va. Code R. § 114-97-3