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 114-95-6 - Operational Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. A
				utilization review program shall use documented clinical review criteria that are
				based on sound clinical evidence and are evaluated periodically to assure ongoing
				efficacy. An issuer may develop its own clinical review criteria or it may purchase
				or license clinical review criteria from qualified vendors. An issuer shall make
				available its clinical review criteria upon request by a person authorized by the
				Commissioner or by statute or legislative rule to receive such
				information.
6.2. Qualified health care
				professionals shall administer the utilization review program and oversee
				utilization review decisions. A clinical peer shall evaluate the clinical
				appropriateness of adverse determinations.
6.3.
Exhaustion.
6.3.a. Whenever an issuer fails to adhere to the
				requirements of section 7 or 8 with respect to making utilization review and benefit
				determinations of a benefit request or claim, the covered person shall be deemed to
				have exhausted the provisions of this rule and may file a request for external
				review in accordance with the procedures outlined in W.Va. Code of St. R. §
										114-97-1
et
				seq.
6.3.a.1. Notwithstanding subdivision
				6.3.a, the provisions of sections 7 or 8 of this rule shall not be deemed exhausted
				based on a
de minimis
violation that does not cause, and is not
				likely to cause, prejudice or harm to the covered person as long as the issuer
				demonstrates that the violation was for good cause or due to matters beyond its
				control and that the violation occurred in the context of an ongoing, good faith
				exchange of information between the issuer and the covered person.
6.3.a.2. The exception described in paragraph
				6.3.a.1 is inapplicable if the violation is part of a pattern or practice of
				violations by the issuer.
6.3.a.3.
				Within ten days of receiving a request from a covered person, an issuer shall
				provide a written explanation of why it believes that any alleged violation of
				sections 7 or 8 of this rule does not constitute a sufficient basis to trigger the
				exhaustion provisions of subdivision 6.3.a.
6.3.a.4. The Commissioner shall resolve any issues
				raised by an issuer as to whether a covered person may, in accordance with paragraph
				6.3.a.1, be deemed to have exhausted the provisions of this rule, and the
				Commissioner's written notice of a determination that such exhaustion requirements
				have not been met shall also inform the covered person that he or she may resubmit
				and, as appropriate, pursue a review of the benefit request or claim under this rule
				or file a grievance pursuant to W.Va. Code of St. R. §
											114-96-1
et
				seq.
6.3.a.5. For purposes of
				calculating the time period for refiling the benefit request or claim, the time
				period shall begin to run upon the covered person's receipt of the notice of
				opportunity to resubmit.