West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-3 - Notice of Right to External Review

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. An issuer
				shall notify the covered person in writing of the covered person's right to request
				an external review. Such a written notice from an issuer of an adverse determination
				upon completion of the issuer's utilization review process or of a final adverse
				determination shall include:
3.1.a. Notice of the
				covered person's right to request an external review to be conducted pursuant to
				section 6, 7 or 8;
3.1.b. The following
				or substantially equivalent language: "We have denied your request for the provision
				of or payment for a health care service or course of treatment. You may have the
				right to have our decision reviewed by health care professionals who have no
				association with us if our decision involved making a judgment as to the medical
				necessity, appropriateness, health care setting, level of care or effectiveness of
				the health care service or treatment you requested by submitting a request for
				external review to the WV Offices of the Insurance Commissioner, P.O. Box 50540,
				Charleston, WV 25305."
3.1.c. The
				description provided pursuant to section 14 of both the standard and expedited
				external review procedures, highlighting the provisions in the external review
				procedures that give the covered person the opportunity to submit additional
				information and including any forms used to process an external review
				request.
3.1.d. A form approved by the
				Commissioner by which the covered person authorizes the issuer and the covered
				person's treating health care provider to disclose protected health information,
				including medical records, concerning the covered person that are pertinent to the
				external review.
3.1.e. For a notice
				related to an adverse determination, a statement informing the covered person that:
3.1.e.1. If he or she has a medical condition
				where the time-frame for expedited review of a grievance under the issuer's internal
				grievance process would seriously jeopardize his or her life, health or ability to
				regain maximum function, he or she may file with the Commissioner, simultaneously
				with a request for expedited review under the issuer's internal grievance process, a
				request for expedited external review to be conducted pursuant to section 7 or, in
				cases involving denials based on the issuer's determination that the treatment or
				service is experimental or investigational where the covered person's treating
				physician certifies in writing that the recommended or requested service or
				treatment would be significantly less effective if not promptly initiated, pursuant
				to section 8; and
3.1.e.2. The covered
				person may file a grievance under the issuer's internal grievance process, but if
				the issuer has not issued a written decision to the covered person within thirty
				days, he or she shall, except to the extent he or she requested or agreed to a
				delay, be considered to have exhausted the issuer's internal grievance process for
				the purposes of filing a request for external review pursuant to section
				5.
3.1.f. For a notice
				related to a final adverse determination, a statement informing the covered person
				that:
3.1.f.1. If the covered person has a medical
				condition where the timeframe for completion of a standard external review pursuant
				to section 6 would seriously jeopardize the covered person's life or health or
				ability to regain maximum function, the covered person may file a request for an
				expedited external review pursuant to section 7; or
3.1.f.2. If the final adverse determination
				concerns:
3.1.f.2.A. An admission, availability of
				care, continued stay or health care service for which the covered person received
				emergency services, but has not been discharged from a facility, the covered person
				may request an expedited external review pursuant to section 7; or
3.1.f.2.B. A denial of coverage based on a
				determination that the recommended or requested health care service or treatment is
				experimental or investigational, the covered person may file a request for a
				standard external review to be conducted pursuant to section 8 or, if the covered
				person's treating physician certifies in writing that the recommended or requested
				health care service or treatment that is the subject of the request would be
				significantly less effective if not promptly initiated, the covered person may
				request an expedited external review to be conducted under subsection 8.2.