West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-7 - Expedited Reviews of Grievances Involving an Adverse Determination

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. An issuer shall establish written procedures
				for the expedited review of urgent care requests of grievances involving an adverse
				determination.
7.2. In addition to
				subsection 7.1, an issuer shall provide expedited review of a grievance involving an
				adverse determination with respect to concurrent review urgent care requests
				involving an admission, availability of care, continued stay or health care service
				for a covered person who has received emergency services, but has not been
				discharged from a facility.
7.3. The
				procedures shall allow a covered person to request an expedited review under this
				section orally or in writing.
7.4. An
				issuer shall appoint an appropriate clinical peer or peers in the same or similar
				specialty as would typically manage the case being reviewed to review the adverse
				determination. The clinical peer or peers shall not have been involved in making the
				initial adverse determination.
7.5. In
				an expedited review, all necessary information, including the issuer's decision
				shall be transmitted between the issuer and the covered person by telephone,
				facsimile or the most expeditious method available.
7.6. An expedited review decision shall be made
				and the covered person shall be notified of the decision in accordance with
				subsection 7.8 as expeditiously as the covered person's medical condition requires,
				but in no event more than seventy-two hours after the receipt of the request for the
				expedited review. If the expedited review of a grievance involves an adverse
				determination with respect to a concurrent review urgent care request, the service
				shall be continued without liability to the covered person until the covered person
				has been notified of the determination.
7.7. For purposes of calculating the time periods
				within which a decision is required to be made under subsection 7.6, the time period
				within which the decision is required to be made shall begin on the date the request
				is filed with the issuer in accordance with the issuer's procedures established
				pursuant to section 4 for filing a request without regard to whether all of the
				information necessary to make the determination accompanies the filing.
7.8. Decision Notification.
7.8.a. A notification of a decision under this
				section shall, in a manner calculated to be understood by the covered person, set
				forth:
7.8.a.1. The titles and qualifying
				credentials of the person or persons participating in the expedited review process
				(the reviewers);
7.8.a.2. Information
				sufficient to identify the claim involved with respect to the grievance, including
				the date of service, the health care provider and, if applicable, the claim
				amount;
7.8.a.3. A statement describing
				the availability, upon request, of the diagnosis code and its corresponding meaning,
				and the treatment code and its corresponding meaning. For purposes of this
				paragraph, an issuer:
7.8.a.3.A. Shall upon
				request provide to the covered person, as soon as practicable, the diagnosis code
				and its corresponding meaning and the treatment code and its corresponding meaning,
				associated with any adverse determination; and
7.8.a.3.B. Shall not consider a request for the
				diagnosis code and treatment information, in itself, to be a request for external
				review pursuant to W.Va. Code of St. R. §
												114-97-1
et
				seq.;
7.8.a.4. A
				statement of the reviewers' understanding of the covered person's
				grievance;
7.8.a.5. The reviewers'
				decision in clear terms and the contract basis or medical rationale in sufficient
				detail for the covered person to respond further to the issuer's position;
7.8.a.6. A reference to the evidence or
				documentation used as the basis for the decision; and
7.8.a.7. If the decision involves a final adverse
				determination, the notice shall provide:
7.8.a.7.A. The specific reasons or reasons for the
				final adverse determination, including the denial code and its corresponding
				meaning, as well as a description on the issuer's standard, if any, that was used in
				reaching the denial;
7.8.a.7.B.
				Reference to the specific plan provisions on which the determination is
				based;
7.8.a.7.C. A description of any
				additional material or information necessary for the covered person to complete the
				request, including an explanation of why the material or information is necessary to
				complete the request;
7.8.a.7.D. If the
				issuer relied upon an internal rule, guideline, protocol or other similar criterion
				to make the adverse determination, either the specific rule, guideline, protocol or
				other similar criterion or a statement that a specific rule, guideline, protocol or
				other similar criterion was relied upon to make the adverse determination and that a
				copy of the rule, guideline, protocol or other similar criterion will be provided
				free of charge to the covered person upon request;
7.8.a.7.E. If the final adverse determination is
				based on a medical necessity or experimental or investigational treatment or similar
				exclusion or limit, either an explanation of the scientific or clinical judgment for
				making the determination, applying the terms of the health benefit plan to the
				covered person's medical circumstances, or a statement that an explanation will be
				provided to the covered person free of charge upon request;
7.8.a.7.F. If applicable, instructions for
				requesting:
7.8.a.7.F.1. A copy of the rule
				guideline, protocol or other similar criterion relied upon in making the adverse
				determination in accordance with subparagraph 7.8.a.7.D;
7.8.a.7.F.2. The written statement of the
				scientific or clinical rationale for the adverse determination in accordance with
				subparagraph 7.8.a.7.E;
7.8.a.7.F.3. A
				statement describing the procedures for obtaining an independent external review of
				the adverse determination pursuant to W.Va. Code of St. R. §
													114-97-1 et seq.;
7.8.a.7.F.4. A statement indicating the covered
				person's right to bring a civil action in a court of competent
				jurisdiction;
7.8.a.7.F.5. The following
				statement: "You and your plan may have other voluntary alternative dispute
				resolution options, such as mediation. One way to find out what may be available is
				to contact your state Insurance Commissioner."; and
7.8.a.7.F.6. A notice of the covered person's
				right to contact the Commissioner for assistance with respect to any claim,
				grievance or appeal at any time, including the telephone number and address of the
				Commissioner's office.