Virginia Administrative Code › Title 1 - ADMINISTRATION › Agency 55 - DEPARTMENT OF HUMAN RESOURCE MANAGEMENT › Chapter 20 - COMMONWEALTH OF VIRGINIA HEALTH BENEFITS PROGRAM › Part I - General › Section 1VAC55-20-90 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. The director of
				  the department shall be the final arbiter of any disputes arising under this
				  chapter. The director may not redelegate this authority other than to an
				  independent hearing officer except as provided under subsection C of this
				  section.
All disputes arising under this chapter shall be submitted
					 to the department, which shall have the responsibility for interpreting and
					 administering this chapter. All disputes shall be made in writing in such
					 manner as may be reasonably required by the department and shall set forth the
					 facts which the applicant believes to be sufficient to entitlement to relief
					 hereunder. The department may adopt forms for such submissions in which case
					 all appeals shall be filed on such forms.
B. Appeals not filed within the time frames
				  established herein shall be denied.
Requests for review of procurements under the provisions of
					 the VPPA shall be filed within 10 days of the department's notice of intent to
					 award a contract.
Requests for relief from local employers or state agencies
					 with respect to any action of the department other than a procurement shall be
					 filed within 30 days of the action grieving the applicant. Requests for relief
					 from state or local employees with respect to any action of the department
					 other than a procurement shall be filed within 60 days of the action grieving
					 the employee.
C. Upon
				  receipt by the department for a request for review under this section, it shall
				  determine all facts which are necessary to establish the right of an applicant
				  for relief. The department shall approve, deny or investigate any and all
				  disputes arising hereunder. Upon request, the department will afford the
				  applicant the right of a hearing with respect to any finding of fact or
				  determination related to any claim under this section. In the event of an
				  adverse decision by the department, the applicant shall be notified of such
				  decision as hereinafter provided. Reviews for treatment authorizations or
				  medical claims that have been denied will be sent to an impartial health
				  entity. The impartial health entity shall examine the final denial of claims or
				  treatment authorizations to determine whether the decision is objective,
				  clinically valid, and compatible with established principles of health care.
				  The decision of the impartial health entity shall (i) be in writing, (ii)
				  contain findings of fact as to the material issues in the case and the basis
				  for those findings, and (iii) be final and binding if consistent with law and
				  policy.
D. The applicant shall be
				  notified in writing of any adverse decision with respect to his claim within 90
				  days after its submission. The notice shall be written in a manner calculated
				  to be understood by the applicant and shall include:
1. The specific reason or reasons for the
				  denial;
2. Specific references to
				  law, this chapter, contracts awarded pursuant to this chapter, or the Health
				  Insurance Manual/Local Administrative Manual and related instructions on which
				  the denial is based;
3. A
				  description of any additional material or information necessary to the
				  applicant to perfect the claim and an explanation why such material or
				  information is necessary; and
4. An
				  explanation of the review process.
If special circumstances require an extension of time for
					 processing an initial application, the department shall furnish written notice
					 of the extension and the reason therefore to the applicant before the end of
					 the initial 90-day period. In no event shall such extension exceed 90
					 days.