W. Va. Code R. § 114-97-6

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

Section 114-97-6 - Standard External Review

6.1. Within four months of receipt of a notice of an adverse determination or final adverse determination, a covered person may file a request for an external review with the Commissioner and, within two business of receipt of such a request, the Commissioner shall forward a copy to the issuer,

6.2. Within five business days following receipt of a copy of a covered person's external review request from the Commissioner, the issuer shall send the Commissioner and the covered person its determination whether the request is complete and if it is eligible for external review; such determinations shall be based on consideration of the following:

6.2.a. The individual is or was a covered person at the time the health care service was requested or, in the case of retrospective review, was a covered person in the health benefit plan at the time the health care service was provided;

6.2.b. The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the health benefit plan, but for a determination by the issuer that the health care service is not covered because it does not meet the issuer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness;

6.2.c. The covered person is deemed to have exhausted the issuer's internal grievance process; and

6.2.d. The covered person has provided all the information and forms required to process an external review.

6.3. If the request:

6.3.a Is not complete, the issuer shall inform the covered person and the Commissioner in writing and include in the notice what information or materials are needed to make the request complete; or

6.3.b. Is not eligible for external review, the issuer shall inform the covered person and the Commissioner in writing of the reasons for its ineligibility; such notice shall also include a statement that such determination is made in accordance with the terms of the covered person's plan, subject to the provisions of this rule, and that it may be appealed to the Commissioner.

6.4. Notwithstanding a issuer's initial determination to the contrary, the Commissioner may determine that a request is eligible for external review and require that it be referred for external review; such decision is not reviewable.

6.5. Within two business days after the Commissioner receives a notice that the issuer has determined that the request is eligible for external review or after the Commissioner determines pursuant to subsection 6.4 that a request is eligible for external review, he or she shall assign an IRO and notify the covered person and issuer in writing of such assignment. The assignment shall be done on a random basis among those approved IROs qualified to conduct the particular external review, based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and on other circumstances, including conflict of interest concerns.

6.5.a. The Commissioner shall include in the notice of IRO assignment a statement that the covered person may submit in writing to the assigned IRO, within five business days following receipt of such notice, additional information that the IRO shall consider when conducting the external review and that, in its sole discretion, the IRO may accept and consider additional information submitted after five business days. Within one business day of receipt of any information submitted pursuant to this subdivision, the IRO shall forward a copy to the issuer.

6.5.b. Within five business days after receipt of the notice provided pursuant to subsection 6.5, the issuer or its designee utilization review organization shall provide to the assigned IRO the documents and any information considered in making the adverse determination or final adverse determination; failure to provide the documents and information within the time specified may be grounds for the IRO to terminate the external review and make a decision to reverse the adverse determination or final adverse determination.

6.6. In addition to the documents and information provided pursuant to subsection 6.5, the assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, shall consider the following in reaching a decision:

6.6.a. The covered person's medical records;

6.6.b. The attending health care professional's recommendation;

6.6.c. Consulting reports from appropriate health care professionals and other documents submitted by the issuer, covered person, the covered person's authorized representative, or the covered person's treating provider;

6.6.d. The terms of coverage under the covered person's health benefit plan to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the issuer;

6.6.e. The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards and associations;

6.6.f. Any applicable clinical review criteria developed and used by the issuer or its designee utilization review organization; and

6.6.g. The opinion of the IRO's clinical review or reviewers after considering subdivisions 6.6.a through 6.6.f to the extent the clinical reviewers consider appropriate.

6.7. In reaching a decision, the assigned IRO is not bound by any decisions or conclusions reached during the issuer's utilization review process or the issuer's internal grievance process.

6.8.IRO decision. Within forty-five days after receipt of the request for an external review and no later than one business day after making the decision, the assigned IRO shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person, the issuer and the Commissioner. The decision shall include a general description of the reason for the request for external review; the dates on which the IRO received the assignment from the Commissioner to conduct the external review and when external review was conducted; the principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision; the rationale for its decision; and references to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.

6.9.Termination of external review.

6.9.a. Upon receipt of a notice of a decision pursuant to subsection 6.8 reversing the adverse determination or final adverse determination, the issuer shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.

6.9.b. The IRO shall terminate external review proceedings upon receipt of notice from the issuer that it has reversed its adverse determination or final adverse determination and will provide coverage or payment for the health care service that is the subject of the adverse determination or final adverse determination.

W. Va. Code R. § 114-97-6