reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part IV - Services › Section 14VAC5-211-165 - Point-of-service benefits

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  health maintenance organization shall offer point-of-service benefits to its
				  enrollees in the large group market in accordance with the provisions of §
				  38.2-3407.12 of the Code of Virginia.
B. If point-of-service benefits are chosen, a
				  description of the procedure for obtaining point-of-service benefits and
				  notification requirements before obtaining these benefits shall be included in
				  the evidence of coverage as well as a description of the restrictions or
				  limitations on such benefits.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part IV - Services › Section 14VAC5-211-170 - Supplemental health care services

Current through Register Vol. 40, No. 24, July 15, 2024
In addition to the basic health care services required to
					 be provided in
					 14VAC5-211-160, a health
					 maintenance organization may offer to its enrollees any supplemental health
					 care services it chooses to provide, as allowed by applicable law. These
					 services may or may not be subject to cost sharing limitations or out-of-pocket
					 or deductible maximums that are applicable to basic health care
					 services.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part IV - Services › Section 14VAC5-211-180 - Out-of-area services

Current through Register Vol. 40, No. 24, July 15, 2024
In addition to out-of-area emergency services required to
					 be provided as basic health care services, a health maintenance organization
					 may offer indemnity benefits covering out-of-area services to its enrollees. A
					 description of the procedure for obtaining out-of-area services and
					 notification requirements before obtaining these services shall be included in
					 the evidence of coverage as well as a description of restrictions or
					 limitations on out-of-area services. Except for out-of-area emergency services,
					 a health care plan that requires the enrollee to contact the health maintenance
					 organization before obtaining out-of-area services shall provide for telephone
					 consultation on a 24-hour per day, seven-day per week basis.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part IV - Services › Section 14VAC5-211-190 - Limited health care services

Current through Register Vol. 40, No. 24, July 15, 2024
A. A health maintenance organization may
				  offer limited health care services in either dental care or vision care
				  services.
B. A health maintenance
				  organization shall be reasonably assured that the enrollee has obtained
				  pediatric oral essential health benefits from an exchange-certified stand-alone
				  dental plan for coverage purchased in the individual or small group markets
				  outside the health insurance exchange. A health maintenance organization shall
				  be deemed to have obtained reasonable assurance that such pediatric oral health
				  benefits are provided to the enrollee if:
1.
				  At least one qualified dental plan, as defined in § 38.2-3455 of the Code
				  of Virginia, (i) offers the minimum essential pediatric oral health benefits
				  that are required under the ACA and (ii) is available for purchase by a
				  subscriber or enrollee; and
2. The
				  health maintenance organization prominently discloses, in a form approved by
				  the commission, at the time that it offers the health benefit plan that the
				  plan does not provide ACA-required minimum essential pediatric oral health
				  benefits.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part V - Disclosure and Prohibitions › Section 14VAC5-211-200 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part V - Disclosure and Prohibitions › Section 14VAC5-211-220 - Preexisting conditions and waiting periods

Current through Register Vol. 40, No. 24, July 15, 2024
A. In accordance with § 38.2-3444 of the
				  Code of Virginia, a health maintenance organization shall not limit or exclude
				  coverage for an enrollee by imposing a preexisting condition exclusion. This
				  section shall apply to any health maintenance organization providing a health
				  benefit plan in the individual or group markets, including a grandfathered
				  group health plan, but not including a grandfathered plan for individual health
				  insurance coverage.
B. A waiting
				  period not to exceed 90 days may be allowed for a group health plan or excepted
				  benefits policies or contracts that do not provide for essential health
				  benefits. Any waiting period is deemed to commence on the enrollment date for
				  group coverage or the effective date of the policy, as applicable.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part V - Disclosure and Prohibitions › Section 14VAC5-211-230 - Reasons for termination or rescission

Current through Register Vol. 40, No. 24, July 15, 2024
A. A health maintenance organization shall
				  not terminate an enrollee's coverage for services provided under a health
				  maintenance organization contract except for one or more of the following
				  reasons:
1. Failure to pay the premium
				  required by the contract as shown in the contract or evidence of
				  coverage;
2. The policyholder or
				  contract holder has performed an act or practice that constitutes fraud or made
				  an intentional misrepresentation of material fact in connection with the
				  coverage;
3. The group contract
				  holder has failed to comply with a material plan provision relating to employer
				  contribution or group participation rules; or
4. Discontinuance of the group contract under
				  which the enrollee was covered.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part V - Disclosure and Prohibitions › Section 14VAC5-211-240 - Unfair discrimination

Current through Register Vol. 40, No. 24, July 15, 2024
A health maintenance organization shall not unfairly
					 discriminate against an enrollee on the basis of the age, sex, health status,
					 race, color, creed, national origin, ancestry, religion, marital status, or
					 lawful occupation of the enrollee, or because of the frequency of utilization
					 of services by the enrollee.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part VI - General Provisions › Section 14VAC5-211-250 - Conformity with state law

Current through Register Vol. 40, No. 24, July 15, 2024
A contract or evidence of coverage that contains a
					 provision that conflicts with the requirements of this chapter or the
					 provisions of Chapter 43 (§ 38.2-4300 et seq.) or Chapter 58 (§
					 38.2-5800 et seq.) of Title 38.2 of the Code of Virginia shall not be rendered
					 invalid but shall be construed and applied as if it were in full compliance
					 with the requirements of this chapter and Chapters 43 and 58 of Title 38.2 of
					 the Code of Virginia.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part VI - General Provisions › Section 14VAC5-211-260 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part VI - General Provisions › Section 14VAC5-211-270 - Controversies involving contracts

Current through Register Vol. 40, No. 24, July 15, 2024
The commission shall have no jurisdiction to adjudicate
					 controversies between a health maintenance organization and its enrollees. A
					 breach of contract shall not be deemed a violation of this
					 chapter.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part VI - General Provisions › Section 14VAC5-211-280 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter or its application to any
					 person or circumstance is for any reason held to be invalid, the remainder of
					 the chapter and the application of the provisions to other persons or
					 circumstances shall not be affected.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part VI - General Provisions › Section - DOCUMENTS INCORPORATED BY REFERENCE (14VAC5-211)

Current through Register Vol. 40, No. 24, July 15, 2024
Accounting Practices and Procedures Manual, Volumes I and
					 II, March 2004, National Association of Insurance Commissioners.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part I - General › Section 14VAC5-216-10 - Scope and purpose

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  This chapter shall apply to all health carriers, except that the provisions of
				  this chapter shall not apply to a policy or certificate that provides coverage
				  only for a specified disease, specified accident or accident-only coverage;
				  credit; disability income; hospital indemnity; long-term care; dental, vision
				  care, or any other limited supplemental benefit or to a Medicare supplement
				  policy of insurance; coverage under a plan through Medicare, Medicaid, or the
				  federal employees health benefits program; self-insured plans except that a
				  self-insured employee welfare benefit plan may elect to use the state external
				  review process; any coverage issued under Chapter 55 of Title 10 of the U.S.
				  Code (TRICARE), and any coverage issued as supplemental to that coverage; any
				  coverage issued as supplemental to liability insurance, workers' compensation
				  or similar insurance; and automobile medical payment insurance or any insurance
				  under which benefits are payable with or without regard to fault, whether
				  written on a group or individual basis.
B. The purpose of this chapter is to set
				  forth rules to carry out the provisions of Chapter 35.1 (§ 38.2-3556 et
				  seq.) of Title 38.2 of the Code of Virginia as well as federal law to provide a
				  health carrier with guidelines to assist with establishing a procedure for an
				  internal appeals process under which there will be a full and fair review of
				  any adverse benefit determination. This chapter also sets forth requirements
				  for the external review process.
C.
				  This chapter shall apply to any adverse benefit determination made on or after
				  July 1, 2011, by any health carrier for a grandfathered or non-grandfathered
				  health benefit plan, as defined by the PPACA.
D. This chapter also sets forth requirements
				  for an exception request for plan years beginning on or after January 1,
				  2016.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-30 - General requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Each health carrier offering a health benefit plan shall establish and maintain
				  an internal appeals procedure in accordance with this chapter, 29 USC §
				  2560.503-1, and 45 CFR
				  147.136 to provide a full and fair review of
				  any adverse benefit determination.
B. As part of each health carrier's health
				  benefit plan and any adverse benefit determination, each health carrier shall
				  provide notice of its available internal appeals procedures (including urgent
				  care appeals), including timeframes for submission of an appeal, the health
				  carrier's review and response. Such notice shall also include the name,
				  address, and telephone number of the person or organizational unit designated
				  to coordinate the review of the appeal for the health carrier, and contact
				  information for the Bureau of Insurance. If the plan is a managed care health
				  insurance plan (MCHIP), the mailing address, telephone number, and email
				  address for the Office of the Managed Care Ombudsman shall also be
				  included.
C. The internal appeals
				  procedure shall not contain any provision, or be administered in a way that
				  unduly inhibits or hampers the initiation or processing of claims for
				  benefits.
D. The internal appeals
				  procedure shall provide for an authorized representative of a covered person to
				  act on behalf of the covered person in pursuing a benefit claim or appeal of an
				  adverse benefit determination. A health carrier may establish reasonable
				  procedures for determining whether an individual has been authorized to act on
				  behalf of a covered person. In the case of an urgent care appeal, a health care
				  professional shall be permitted to act as the authorized representative of the
				  covered person, in accordance with this chapter.
E. The internal appeals procedure shall
				  contain administrative processes and safeguards designed to ensure and to
				  verify that benefit determinations are made in accordance with the provisions
				  of the health benefit plan and, where appropriate, the health benefit plan
				  provisions have been applied consistently with respect to similarly situated
				  covered persons.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-40 - Minimum appeal requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each covered person shall be entitled to a
				  full and fair review of an adverse benefit determination. Within 180 days after
				  the date of receipt of a notice of an adverse benefit determination, a covered
				  person may file an appeal with the health carrier. A health carrier may
				  designate a utilization review entity to coordinate the review. For purposes of
				  this chapter, "health carrier" may also mean its designated utilization review
				  entity.
B. The health carrier shall
				  conduct the appeal in a manner to ensure the independence and impartiality of
				  the individuals involved in reviewing the appeal. In ensuring the independence
				  and impartiality of such individuals, the health carrier shall not make
				  decisions regarding hiring, compensation, termination, promotion, or other
				  similar matters based upon the likelihood that an individual will support the
				  denial of benefits.
C.
1. In deciding an appeal of any adverse
				  benefit determination that is based in whole or in part on a medical judgment,
				  including determinations with regard to whether a particular treatment, drug,
				  or other service is experimental, investigational, or not medically necessary
				  or appropriate, the health carrier shall designate a clinical peer reviewer to
				  review the appeal. The clinical peer reviewer shall not have been involved in
				  any previous adverse benefit determination with respect to the claim.
2. A reviewer of any other type of adverse
				  benefit determination shall be an appropriate person designated by the health
				  carrier. The reviewer of the appeal shall not be the individual who made any
				  previous adverse benefit determination of the subject appeal nor the
				  subordinate of such individual and shall not defer to any prior adverse benefit
				  determination.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-45 - Exhaustion

Current through Register Vol. 40, No. 24, July 15, 2024
A. In addition to
				  the provisions of § 38.2-3560 of the Code of Virginia, the internal appeal
				  process may be deemed exhausted based on a violation of any of the provisions
				  of 14VAC5-216-30 through
				  14VAC5-216-70. The internal appeal
				  process shall not be deemed exhausted based on a de minimis violation that does
				  not cause, and is not likely to cause, prejudice or harm to the covered person
				  so long as the health carrier demonstrates that the violation was for good
				  cause or due to matters beyond the control of the health carrier and that the
				  violation occurred in the context of an ongoing, good faith exchange of
				  information between the health carrier and the covered person. If the violation
				  is part of a pattern or practice of violations by the health carrier, the
				  violation shall not be considered de minimis.
B. The covered person may request a written
				  explanation of the violation from the health carrier, and the health carrier
				  shall provide the written explanation within 10 days, including a specific
				  description of its basis, if any, for asserting that the violation should not
				  cause the internal appeal process to be deemed exhausted, along with a
				  notification of the right to review this matter by an independent review
				  organization. A review by an independent review organization may be requested
				  by the covered person to the commission to determine if the health carrier has
				  met the standard under this section. The covered person must include, as part
				  of the request for review, the written explanation of the violation by the
				  health carrier. The independent review organization shall have a maximum of 10
				  days to conduct this review and provide a written response to the covered
				  person, the health carrier, and the commission. If rejected, within five days
				  the health carrier shall provide the covered person with a notice of the
				  opportunity to resubmit and pursue an internal appeal of the claim.
C. The health carrier shall pay the
				  independent review organization costs incurred for this review.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-50 - Urgent care appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  health carrier shall notify the covered person of its initial benefit
				  determination as soon as possible taking into account medical exigencies, but
				  not later than 72 hours after receipt of the request, unless the covered person
				  fails to provide sufficient information to determine whether, or to what
				  extent, benefits are covered or payable under the health benefit plan. In the
				  case of such failure, the health carrier shall notify the covered person as
				  soon as possible, but not later than 24 hours after receipt of the request, of
				  the specific information necessary to complete the claim. The covered person
				  shall be afforded a reasonable amount of time, taking into account the
				  circumstances, but not less than 48 hours to provide the specified information.
				  The health carrier shall notify the covered person of its benefit determination
				  not later than 48 hours after the earlier of (i) its receipt of the specified
				  information or (ii) the end of the period afforded to the covered person to
				  provide the specified additional information.
B. The notification of an urgent care adverse
				  benefit determination that is based on a medical necessity, appropriateness,
				  health care setting, level of care, effectiveness, experimental or
				  investigational service or treatment, or similar exclusion or limit, shall
				  include a description of the health carrier's urgent care appeal process
				  including any time limits applicable to those procedures and the availability
				  of and procedures for an expedited external review.
C. Upon receipt of an adverse benefit
				  determination, a covered person may submit a request for an urgent care appeal
				  either orally or in writing to the health carrier. Any appeal request made
				  under this section by a treating health care professional shall be handled as
				  an urgent care appeal. If such request is made by the covered person and not
				  the treating health care professional, an individual acting on behalf of the
				  health carrier shall apply the judgment of a prudent layperson who possesses an
				  average knowledge of health and medicine to determine whether the appeal meets
				  urgent care requirements.
D. All
				  necessary information, including the benefit determination on appeal, shall be
				  transmitted between the health carrier and the covered person by telephone,
				  facsimile, or the most expeditious method available.
E. The health carrier shall notify the
				  covered person and the treating health care professional of its benefit
				  determination as soon as possible, taking into account the medical exigencies,
				  but not later than 72 hours after receipt of an urgent care appeal.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-60 - Concurrent review decisions

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  A health carrier shall provide continued coverage pending the outcome of an
				  internal appeal of a concurrent review decision.
B. Any reduction or termination by a health
				  carrier of an approved course of treatment (other than by health benefit plan
				  amendment or termination) to be provided over a period of time or number of
				  treatments shall constitute an adverse benefit determination. The health
				  carrier shall notify the covered person of the adverse benefit determination at
				  a time sufficiently in advance of the reduction or termination to allow the
				  covered person to file an internal appeal and obtain a determination before the
				  benefit is reduced or terminated.
C. Any request by a covered person to extend
				  the course of treatment beyond the period of time or number of treatments that
				  is an urgent care appeal shall be decided as soon as possible, taking into
				  account the medical exigencies. The covered person and the treating health care
				  professional shall be notified of the benefit determination within 72 hours
				  after receipt of the internal appeal.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-65 - Exception request for prescription drugs

Current through Register Vol. 40, No. 24, July 15, 2024
A. For plan years beginning on or after
				  January 1, 2016, notwithstanding any other provision of this chapter, a health
				  carrier shall have a process in place that allows for a covered person or his
				  prescribing physician (or other prescriber) to request and gain access to
				  clinically appropriate drugs not otherwise covered by the health benefit plan,
				  known as an exception request, in accordance with the requirements of
				  45 CFR
				  §156.122(c).
1. A standard exception request shall be
				  reviewed and acted upon within one business day of receipt of the request, and
				  a coverage determination shall be provided to the covered person and
				  prescribing physician no later than 72 hours following receipt of the
				  request.
2. An expedited exception
				  request may be made when exigent circumstances exist. Exigent circumstances
				  exist when the covered person is suffering from a health condition that may
				  seriously jeopardize the covered person's life, health, or ability to regain
				  maximum function or when the covered person is undergoing a current course of
				  treatment using a nonformulary drug. An expedited exception request shall be
				  reviewed and a coverage determination provided to the covered person and
				  prescribing physician no later than 24 hours following receipt of the
				  request.
3. If a health carrier
				  denies coverage as a result of a standard exception request or an expedited
				  exception request, the covered person or prescribing physician may submit an
				  external exception request to the health carrier, requiring that the original
				  exception request and subsequent denial be reviewed by an independent review
				  organization. Such request shall be reviewed and a coverage determination
				  provided to the covered person and prescribing physician no later than 72 hours
				  following receipt of the request if the original request was a standard
				  exception request, or 24 hours following receipt of the request if the original
				  request was an expedited exception request.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part II - Internal Appeal › Section 14VAC5-216-70 - Notification requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  health carrier shall provide a covered person with written or electronic
				  notification of its benefit determination on appeal. The notification of an
				  adverse benefit determination shall be written in easily understandable
				  language and shall set forth the following:
1.
				  Information sufficient to identify the claim involved with respect to the
				  appeal, including the date of service, the health care provider, the claim
				  amount, and a statement describing the availability, upon request, of the
				  diagnosis code and its corresponding meaning, and the treatment code and its
				  corresponding meaning. The health carrier may not consider a request for
				  diagnosis or treatment information, in itself, to be a request for internal
				  appeal;
2. The specific reason or
				  reasons for the adverse benefit determination;
3. Reference to the specific plan provisions
				  on which the adverse benefit determination is made;
4. A statement that the covered person is
				  entitled to receive, upon request and free of charge, reasonable access to and
				  copies of all documents, records, and other information relevant to the covered
				  person's claim for benefits;
5. A
				  statement indicating whether any additional internal appeals are available or
				  whether the covered person has received a final adverse determination. If
				  internal appeals are available, contact information on where to submit the
				  appeal;
6. A statement describing
				  the external review procedures offered by the health carrier and the covered
				  person's right to obtain information about such procedures and the covered
				  person's right to bring a civil action under § 502(a) of ERISA ( 29 USC
				  § 1001 et seq.), if applicable; and
7. A statement indicating that the covered
				  person has the right to request an external review if the covered person has
				  not received a final benefit determination within the timeframes provided in
				  14VAC5-216-40 E, unless the
				  covered person requests or agrees to a delay.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-80 - Incomplete or ineligible determinations

Current through Register Vol. 40, No. 24, July 15, 2024
A. After the covered person has requested an
				  external review, and if he is notified by the health carrier that the request
				  is incomplete in accordance with § 38.2-3561B 4 or 38.2-3563 D 6 of the
				  Code of Virginia, the covered person shall have five business days from receipt
				  of such notice to return the requested materials necessary to complete the
				  request to the health carrier. The health carrier shall then have five business
				  days to conduct the preliminary review for eligibility. Notification shall be
				  in accordance with the provisions of § 38.2-3561C or 38.2-3563E of the
				  Code of Virginia.
B. If the health
				  carrier determines that a covered person's request for external review is
				  complete but ineligible, the covered person may request that the commission
				  review the ineligibility determination.
1.
				  Within five business days from the date the covered person receives
				  notification from the health carrier, the covered person may request in writing
				  that the commission review the ineligibility determination by the health
				  carrier.
2. Within one business day
				  after receipt of a notification from the covered person, the commission shall
				  notify the health carrier of such request.
3. Within three business days of receipt of
				  the commission's notice to the health carrier, the health carrier shall forward
				  all information and materials used to make the ineligibility determination to
				  the commission.
4. Within five
				  business days of receipt of all materials necessary to make an eligibility
				  determination, the commission shall review the file and make such
				  decision.
5. Within one business
				  day of such decision, the commission shall notify the covered person and the
				  health carrier, and the assigned independent review organization if
				  eligible.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-90 - Expedited external review

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  If a covered person files a request with the commission for an expedited
				  external review in accordance with § 38.2-3560C of the Code of Virginia,
				  the health carrier shall promptly conduct an eligibility determination in
				  accordance with
				  14VAC5-216-80 prior to review by
				  an independent review organization.
B. When an independent review organization is
				  requested by the commission in accordance with § 38.2-3562 of the Code of
				  Virginia to conduct an expedited external review of an adverse determination
				  under § 38.2-3560C of the Code of Virginia, the independent review
				  organization shall determine whether the timeframes for sequential completion
				  of the expedited internal appeal and expedited external review (i) could
				  seriously jeopardize the life or health of the covered person or the ability of
				  the covered person to regain maximum function; or (ii) would subject the
				  covered person to severe pain that cannot be adequately managed without the
				  care or treatment that is the subject of the appeal, as compared to the
				  timeframes for simultaneous completion of the expedited appeal and review. The
				  independent review organization shall promptly make such determination and
				  shall promptly notify the covered person, the health carrier, and the
				  commission.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-100 - Qualifications for independent review organizations

Current through Register Vol. 40, No. 24, July 15, 2024
A. An independent review organization that
				  desires to conduct external reviews for the Commonwealth shall submit an
				  application using Form 216-E to the commission for review and approval. An
				  application fee of up to $500 may be required.
B. An independent review organization shall
				  meet all the qualification requirements in § 38.2-3565 of the Code of
				  Virginia.
C. An independent review
				  organization that does not maintain required accreditation status shall provide
				  notice to the commission within 30 days of any change in such status.
Statutory Authority
§ 12.1-13 and § 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-110 - External review reporting requirements

Current through Register Vol. 40, No. 24, July 15, 2024
In accordance with § 38.2-3568 of the Code of
					 Virginia, each health carrier and each independent review organization shall
					 file with the commission a report by April 1 of each calendar year using Form
					 216-F or 216-G as appropriate.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-120 - Funding of external review

Current through Register Vol. 40, No. 24, July 15, 2024
Failure of a health carrier to timely pay any independent
					 review organization for a completed external review shall be a violation of
					 this section and shall subject the health carrier to penalties imposed under
					 Title 38.2 of the Code of Virginia.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Section 14VAC5-216-130 - Self-insured plans

Current through Register Vol. 40, No. 24, July 15, 2024
A. Any
				  self-insured plan whose plan sponsor's headquarters is located in Virginia may
				  choose to utilize the external review processes outlined in Chapter 35.1
				  (§ 38.2-3556 et seq.) of Title 38.2 of the Code of Virginia. For purposes
				  of Part III of this chapter, "health carrier" shall mean a self-insured plan or
				  its third-party administrator if any, that opts in to the state external review
				  process.
B. A self-insured plan
				  utilizing such external review processes shall notify the commission that it
				  will opt-in to the state external review process by completing Form 216-H. A
				  new form shall be completed for each plan year.
C. A self-insured plan that opts in to the
				  state external review process shall comply with all statutes and regulations
				  pertaining to such process. Plan materials and appropriate denial notices shall
				  contain required information regarding the state external review
				  processes.
D. A self-insured plan
				  that opts into the state external review process but fails to comply with the
				  requirements outlined in this chapter and applicable state statutes pertaining
				  to the external review process may be terminated from use of such process by
				  the commission.
Statutory Authority
§ 12.1-13 and 38.2-223 of the Code of
						Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part III - External Review › Form - FORMS (14VAC5-216)

Current through Register Vol. 40, No. 24, July 15, 2024
External
					 Review Request Form, Form 216-A (7/11)
.
Appointment
					 of Authorized Representative, Form 216-B (7/11)
.
Physician
					 Certification Expedited External Review Request, Form 216-C
					 (7/11)
.
Physician
					 Certification Experimental or Investigational Denials, Form 216-D
					 (7/11)
.
Independent
					 Review Organization Application for Registration, Form 216-E
					 (7/11).
Health
					 Carrier External Review Annual Report Form, Form 216-F (7/11)
.
Independent
					 Review Organization External Review Annual Report Form, Form 216-G
					 (7/11)
.
Self-Insured
					 Plan Opt-In to Virginia External Review Process, Form 216-H
					 (7/11)
.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 230 - RULES GOVERNING CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND SICKNESS INSURANCE [REPEALED] › Section 14VAC5-230-10 to 14VAC5-230-110 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 234 - RULES GOVERNING ESSENTIAL AND STANDARD HEALTH BENEFIT PLAN CONTRACTS › Section 14VAC5-234-10 through 14VAC5-234-100 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 12.1-13 and 38.2-223 of
					 the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 234 - RULES GOVERNING ESSENTIAL AND STANDARD HEALTH BENEFIT PLAN CONTRACTS › Form - FORMS (14VAC5-234)

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Primary Small Employer Coverage Report VPSE-1 (eff.
				  5/95).
Virginia Primary Small Employer New Business Report VPSE-2
				  (eff. 5/95).
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 240 - RULES AND REGULATIONS REGARDING PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK INSURERS › Section 14VAC5-240-10 - Application of regulation

Current through Register Vol. 40, No. 24, July 15, 2024
This chapter is applicable to each domestic stock insurer
				  which has any class of equity securities held of record by 100 or more persons;
				  provided, however, that this chapter shall not apply to any insurer if 95% or
				  more of its equity securities are owned or controlled by a parent or an
				  affiliated insurer and the remaining securities are held of record by less than
				  500 persons. A domestic stock insurer which files with the Securities and
				  Exchange Commission forms of proxies, consents and authorizations complying
				  with the requirements of the Securities and Exchange Act of 1934, 15 USC §
				  78a et seq., as amended, and the applicable regulations promulgated thereunder,
				  shall be exempt from the provisions of this chapter with respect to any class
				  of securities subject to SEC jurisdiction.
Statutory Authority
§ 38.2-202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 240 - RULES AND REGULATIONS REGARDING PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK INSURERS › Section 14VAC5-240-20 - Proxies, consents and authorizations

Current through Register Vol. 40, No. 24, July 15, 2024
No domestic stock insurer, or any director, officer or
				  employee of such insurer subject to
				  14VAC5-240-10, or any other
				  person, shall solicit, or permit the use of his name to solicit by mail or
				  otherwise, any proxy, consent or authorization in respect of any class of
				  equity security of such insurer held of record by 100 or more persons in
				  contravention of this chapter and Schedules A and B hereto annexed and hereby
				  made a part of this chapter.
Statutory Authority
§ 38.2-202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 240 - RULES AND REGULATIONS REGARDING PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK INSURERS › Section 14VAC5-240-30 - Disclosure of equivalent information

Current through Register Vol. 40, No. 24, July 15, 2024
Unless proxies, consents or authorizations in respect of any
				  class of equity security of a domestic insurer subject to
				  14VAC5-240-10 hereof are solicited
				  by or on behalf of the management of such insurer from the holders of record of
				  such security in accordance with this chapter and the schedules hereunder prior
				  to any annual or other meeting of such security holders, such insurers shall,
				  in accordance with this chapter and such further regulations as the State
				  Corporation Commission may adopt, file with the Commissioner of Insurance of
				  Virginia (hereinafter referred to as "the Commissioner") and transmit to all
				  security holders of record information substantially equivalent to the
				  information which would be required to be transmitted if a solicitation were
				  made. Such insurer shall transmit a written information statement containing
				  the information specified in subsection D of
				  14VAC5-240-50 to every security
				  holder who is entitled to vote in regard to any matter to be acted upon at the
				  meeting and from whom a proxy is not solicited on behalf of the management of
				  the insurer; provided, that in the case of a class of securities in
				  unregistered or bearer form such statement need be transmitted only to those
				  security holders whose names and addresses are known to the
				  insurer.
Statutory Authority
§ 38.2-202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 240 - RULES AND REGULATIONS REGARDING PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK INSURERS › Section 14VAC5-240-40 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
A. The definitions
				and instructions set out in Schedule SIS, as promulgated by the National
				Association of Insurance Commissioners, shall be applicable for purposes of
				this chapter.
B. The terms
				"solicit" and "solicitation" for purposes of this chapter shall include:
1. Any request for a proxy, whether or not
				accompanied by or included in a form of proxy; or
2. Any request to execute or not to execute,
				or to revoke, a proxy; or
3. The
				furnishing of a form of proxy or other communication to security holders under
				circumstances reasonably calculated to result in the procurement, withholding
				or revocation of a proxy.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 240 - RULES AND REGULATIONS REGARDING PROXIES, CONSENTS AND AUTHORIZATIONS OF DOMESTIC STOCK INSURERS › Section 14VAC5-240-50 - Information to be furnished to security holders

Current through Register Vol. 40, No. 24, July 15, 2024
A. No solicitation subject to this chapter
				shall be made unless each person solicited is concurrently furnished or has
				previously been furnished with a written proxy statement containing the
				information specified in Schedule A.
B. If the solicitation is made on behalf of
				the management of the insurer and relates to an annual meeting of security
				holders at which directors are to be elected, each proxy statement furnished
				pursuant to subsection A hereof shall be accompanied or preceded by an annual
				report (in preliminary or final form) to such security holders containing such
				financial statements for the last fiscal year as are referred to in Schedule
				SIS under the heading "Financial Reporting to Stockholders." Subject to the
				foregoing requirements with respect to financial statements, the annual report
				to security holders may be in any form deemed suitable by the
				management.
C. Two copies of each
				report sent to the security holders pursuant to this section shall be mailed to
				the Commissioner not later than the date on which such report is first sent or
				given to security holders or the date on which preliminary copies of
				solicitation material are filed with the Commissioner pursuant to subsection A
				of 14VAC5-240-70, whichever date is
				later.
D. If no solicitation is
				being made by management of the insurer with respect to any annual or other
				meeting, such insurer shall mail to every security holder of record at least 20
				days prior to the meeting date, an information statement as required by
				14VAC5-240-30, containing the
				information called for by all of the Items of Schedule A, other than Items 1, 3
				and 4 thereof, which would be applicable to any matter to be acted upon at the
				meeting if proxies were to be solicited in connection with the meeting. If such
				information statement relates to an annual meeting at which directors are to be
				elected, it shall be accompanied by an annual report to such security holders
				in the form provided in subsection B hereof.
Statutory Authority
§ 38.2-202 of the Code of Virginia.