West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Appendix H

Current through Register Vol. XLI, No. 28, July 12, 2024
Guidelines for long-term care independent review
				  entities
In order for an organization to qualify as an independent review
				  organization for long-term care insurance benefit trigger decisions, it shall comply
				  with all of the following:
a. The independent review organization shall ensure that all
				  health care professionals on its staff and with whom it contracts to provide benefit
				  trigger determination reviews hold a current unrestricted license or certification
				  to practice a health care profession in the United States.
b. The independent review organization shall ensure that any
				  health care professional on its staff and with whom it contracts to provide benefit
				  trigger determination reviews who is a physician holds a current certification by a
				  recognized American medical specialty board in a specialty appropriate for
				  determining an insured's functional or cognitive impairment.
c. The independent review organization shall ensure that any
				  health care professional on its staff and with whom it contracts to provide benefit
				  trigger determination reviews who is not a physician holds a current certification
				  in the specialty in which that person is licensed, by a recognized American
				  specialty board in a specialty appropriate for determining an insured's functional
				  or cognitive impairment.
d. The independent review organization shall ensure that all
				  health care professionals on its staff and with whom it contracts to provide benefit
				  trigger determination reviews have no history of disciplinary actions or sanctions
				  including, but not limited to, the loss of staff privileges or any participation
				  restriction taken or pending by any hospital or state or federal government
				  regulatory agency.
e. The independent review organization shall ensure that neither
				  it, nor any of its employees, agents, or licensed health care professionals,
				  utilized for benefit trigger determination reviews receives compensation of any type
				  that is dependent on the outcome of the review.
f. The independent review organization shall ensure that neither
				  it, nor any of its employees, agents, or licensed health care professionals it
				  utilizes for benefit trigger determination reviews are in any manner related to,
				  employed by or affiliated with the insurer, insured or with a person who previously
				  provided medical care or long term care services to the insured.
g. The independent review organization shall provide a description
				  of the qualifications of the reviewers retained to conduct independent review of
				  long-term care insurance benefit trigger decisions, including the reviewer's current
				  and past employment history, practice affiliations and a description of past
				  experience with decisions relating to long-term care, functional capacity,
				  dependency in activities of daily living, or in assessing cognitive impairment.
				  Specifically, with regard to reviews of tax qualified long-term care insurance
				  contracts, it must demonstrate the ability to assess the severity of cognitive
				  impairment requiring substantial supervision to protect the individual from harm, or
				  with assessing deficits in the ability to perform without substantial assistance
				  from another person at least two activities of daily living for a period of at least
				  90 days due to a loss of functional capacity.
h. The independent review organization shall provide a description
				  of the procedures employed to ensure that reviewers conducting independent reviews
				  are appropriately licensed, registered or certified; trained in the principles,
				  procedures and standards of the independent review organization; and knowledgeable
				  about the functional or cognitive impairments associated with the diagnosis and
				  disease staging processes, including expected duration of such impairment, which is
				  the subject of the independent review.
i. The independent review organization shall provide the number of
				  reviewers retained by the independent review organization and a description of the
				  areas of expertise available from such reviewers and the types of cases such
				  reviewers are qualified to review (e.g., assessment of cognitive impairment or
				  inability to perform activities of daily living due to a loss of functional
				  capacity).
j. The independent review organization shall provide a description
				  of the policies and procedures employed to protect confidentiality of protected
				  health information, in accordance with federal and state law.
k. The independent review organization shall provide a description
				  of its quality assurance program.
l. The independent review organization shall provide the names of
				  all corporations and organizations owned or controlled by the independent review
				  organization or which own or control the organization, and the nature and extent of
				  any such ownership or control. The independent review organization shall ensure that
				  neither it, nor any of its employees, agents, or licensed health care professionals
				  utilized are not a subsidiary of, or owned or controlled by, an insurer or by a
				  trade association of insurers of which the insured is a member.
m. The independent review organization shall provide the names and
				  resumes of all directors, officers and executives of the independent review
				  organization.