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 114-95-7 - Procedures for Standard Utilization Review and Benefit Determinations

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1.
Time
				periods.
7.1.a.
Written
				procedures.
An issuer shall maintain written procedures pursuant to this
				section for making standard utilization review and benefit determinations on
				requests submitted to the issuer by covered persons and for notifying covered
				persons of its determinations with respect to these requests within the specified
				time frames required under this section.
7.1.b.
Calculation of days.
For
				purposes of calculating the time periods within which prospective and retrospective
				review determinations are required to be made, the time period within which the
				determination is required to be made shall begin on the date the request is received
				by 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.
7.1.c.
Prospective review
				determinations.
Within a reasonable period of time appropriate to the covered
				person's medical condition but in no event later than fifteen days after receiving
				the request for a prospective review determination, an issuer shall notify the
				covered person of such determination.
7.1.d.
Retrospective review
				determinations.
For retrospective review determinations, an issuer shall
				notify the covered person of such determination within a reasonable period of time,
				but in no event later than thirty days after receiving the benefit
				request,
7.1.e.
Concurrent review
				determinations.
For a concurrent review determination, if an issuer has
				previously certified an ongoing course of treatment to be provided over a period of
				time or number of treatments:
7.1.e.1. Any
				reduction or termination by the issuer during the course of treatment before the end
				of the period or number of treatments, other than by health benefit plan amendment
				or termination of the health benefit plan, shall constitute an adverse
				determination;
7.1.e.2. The issuer shall
				notify the covered person of the adverse determination in accordance with subsection
				7.3 at a time sufficiently in advance of the reduction or termination to allow the
				covered person to file a grievance to request a review of the adverse determination
				pursuant to W.Va. Code of St. R. § 114 -96-1
et seq.
and
				obtain a determination with respect to that review of the adverse determination
				before the benefit is reduced or terminated; and
7.1.e.3. The health care service or treatment that
				is the subject of the adverse determination shall be continued without liability to
				the covered person with respect to the internal review request made pursuant to
				W.Va, Code of St. R. § 114 -96-1
et seq.
7.1.f
Extensions.
7.1.f.1. The time period for making a prospective
				or retrospective review determination and notifying the covered person of such
				determination pursuant to subdivision 7.1 .a may be extended one time by the issuer
				for up to fifteen days, provided the issuer determines that an extension is
				necessary due to matters beyond the its control and notifies the covered person,
				prior to the expiration of the initial fifteen-day time period for a prospective
				review and the expiration of the initial thirty-day time period for a retrospective
				review, of the circumstances requiring the extension of time and the date by which
				the issuer expects to make a determination.
7.1.f.2. If the extension under this subdivision
				is necessary due to the failure of the covered person to submit information
				necessary to reach a determination on the request, the notice of extension shall
				specifically describe the required information necessary to complete the request and
				give the covered person at least forty-five days from the date of receipt of the
				notice to provide the specified information.