W. Va. Code R. § 114-97-7

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

Section 114-97-7 - Expedited External Review

7.1. Except for retrospective adverse or final adverse determinations, a covered person may make a written request for an expedited external review with the Commissioner at the time the covered person receives an adverse determination that meets the conditions described in the notice required by subdivision 3.1.e or a notice of a final adverse determination that meets any of the conditions described in the notice required by subdivision 3.1.f.

7.2. The Commissioner shall immediately send a copy of a request for an expedited external review to the issuer, who shall immediately make an initial determination whether the request meets the reviewability requirements set forth in subsection 6.2 and immediately notify the Commissioner and the covered person of its initial determination.

7.2.a. If the issuer's initial determination is that an external review request is ineligible for review, the notice required under subsection 7.2 shall include a statement informing the covered person that the initial determination may be appealed to the Commissioner.

7.2.b. Notwithstanding an 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 and must be made in accordance with the terms of the covered person's plan, subject to the provisions of this rule.

7.3. Within one business day after the Commissioner receives a notice that a request is eligible for external review (following the preliminary review conducted by the IRO pursuant to subsection 7.2) or after the Commissioner determines pursuant to subdivision 7.2.b that a request is eligible for external review, he or she shall immediately assign an IRO in accordance with subsection 6.5 and notify the covered person and issuer of such assignment.

7.4. Upon receipt of notice of the IRO assignment, the issuer or its designee utilization review organization shall transmit to the assigned IRO all documents and information considered in making the adverse determination or final adverse determination; such transmission shall be made electronically, by telephone or facsimile, or by any other available expeditious method.

7.5. In addition to the documents and information provided or transmitted pursuant to subsection 7.4, the assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, shall consider the information listed in subsection 6.6.

7.6. As expeditiously as the covered person's medical condition or circumstances require, but in no event more than seventy-two hours after receipt of the request for an expedited external review that the assigned IRO determined has met the reviewability requirements set forth in subsection 6.2 or of a decision by the Commissioner pursuant to subdivision 7.2.b that the request is eligible for external review, the assigned IRO shall notify the covered person, the issuer, and the Commissioner of its decision to either uphold or reverse the adverse determination or final adverse determination electronically, by telephone or facsimile, or by any other available expeditious method.

7.7. Within forty-eight hours after providing notice of the IRO's decision provided pursuant to subsection 7.6, the IRO shall provide written confirmation of the decision to the covered person, the issuer, and the Commissioner and include in such notice the information set forth in subsection 6.8.

7.8. Upon receipt of the notice a decision pursuant to subsection 7.6 to reverse the adverse determination or final adverse determination, the issuer immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.

W. Va. Code R. § 114-97-7