West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-8 - Procedures for Expedited Utilization Review and Benefit Determinations

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. An issuer shall
				establish written procedures in accordance with this section for receiving benefit
				requests from covered persons and for making and notifying covered persons of
				expedited utilization review and benefit determinations with respect to urgent care
				requests and concurrent review urgent care requests.
8.1.a. Such procedures must include that, in the
				case of a failure by a covered person to provide sufficient information, the issuer
				shall notify the covered person either orally or, if requested by the covered
				person, in writing of this failure and state what specific information is needed as
				soon as possible, but in no event later than twenty-four hours after receipt of the
				request, and the issuer shall provide the covered person a reasonable period of time
				to submit the necessary information, taking into account the circumstances, but in
				no event less than forty-eight hours after notifying the covered person of the
				failure to submit sufficient information. The provisions of this subdivision only
				apply in the case of a failure that is a communication by a covered person that is
				received by a person or organizational unit of the issuer responsible for handling
				benefit matters and that refers to a specific covered person, a specific medical
				condition or symptom, and a specific health care service, treatment or provider for
				which certification is being requested.
8.1.b. For an urgent care request, unless the
				covered person has failed to provide sufficient information for the issuer to
				determine whether, or to what extent, the benefits requested are covered benefits or
				payable under the issuer's health benefit plan, the issuer shall notify the covered
				person of the issuer's determination with respect to the request, whether or not the
				determination is an adverse determination, as soon as possible, taking into account
				the medical condition of the covered person, but in no event later than seventy-two
				hours after the receipt of the request by the issuer.
8.1.b.1. If the covered person has failed to
				provide sufficient information for the issuer to determine whether, or to what
				extent, the benefits requested are covered benefits or payable under the issuer's
				health benefit plan, the issuer shall notify the covered person as soon as possible,
				but in no event later than twenty-four (24) hours after receipt of the request,
				either orally or, if requested by the covered person, in writing of this failure and
				state what specific information is needed. The issuer shall provide the covered
				person a reasonable period of time to submit the necessary information, taking into
				account the circumstances, but in no event less than forty-eight (48) hours after
				notifying the covered person or the covered person's authorized representative of
				the failure to submit sufficient information.
8.1.b.2. The issuer shall notify the covered
				person of its determination with respect to the urgent care request as soon as
				possible, but in no event more than forty-eight hours after the earlier of:
8.1.b.2.A. The issuer's receipt of the requested
				specified information; or
8.1.b.2.B. The
				end of the period provided for the covered person to submit the requested specified
				information.
8.1.b.3. If the
				covered person fails to submit the information before the end of the period of the
				extension, as specified in subparagraph 8.1.b.2.B, the issuer may deny the
				certification of the requested benefit.
8.1.c. For concurrent review urgent care requests
				involving a request by the covered person to extend the course of treatment beyond
				the initial period of time or the number of treatments, if the request is made at
				least twenty-four hours prior to the expiration of the prescribed period of time or
				number of treatments, the issuer shall make a determination with respect to the
				request and notify the covered person of the determination, whether it is an adverse
				determination or not, as soon as possible, taking into account the covered person's
				medical condition, but in no event more than twenty-four hours after the issuer's
				receipt of the request.
8.1.d. For
				purposes of calculating the time periods within which a determination is required to
				be made under subsection 8.2, the time period within which the determination 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 5 for filing
				a request without regard to whether all of the information necessary to make the
				determination accompanies the filing.