W. Va. Code R. § 114-95-8

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-95-8 - Procedures for Expedited Utilization Review and Benefit Determinations

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.

8.2.Notice Requirements.

8.2.a. A notification of an adverse determination under this section shall, in a manner calculated to be understood by the covered person, set forth;

8.2.a.1. Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care provider and the claim amount, if applicable;

8.2.a.2. A statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning. For purposes of this paragraph, an issuer:

8.2.a.2.A. Shall provide to the covered person, as soon as practicable, upon request, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, associated with any adverse determination; and

8.2.a.2.B. May not consider a request for the diagnosis code and treatment information, in itself, to be a request to file a grievance for review of an adverse determination pursuant to W.Va. Code of St. R. § 114-96-1et seq., or a request for external review;

8.2.a.3. The specific reasons or reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the issuer's standard, if any, that was used in denying the benefit request or claim;

8.2.a.4. Reference to the specific plan provisions on which the determination is based;

8.2.a.5. A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;

8.2.a.6. A description of the issuer's internal review and expedited review procedures established pursuant to W.Va. Code of St. R. § 114-96-1et seq., including any time limits applicable to those procedures;

8.2.a.7. If the issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol or other similar criterion or a statement that a specific rule, guideline, protocol or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol or other similar criterion will be provided free of charge to the covered person upon request;

8.2.a.8. If the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request;

8.2.a.9. If applicable, instructions for requesting:

8.2.a.9.A. A copy of the rule, guideline, protocol or other similar criterion relied upon in making the adverse determination in accordance with paragraph 8.2.a.7; or

8.2.a.9.B. The written statement of the scientific or clinical rationale for the adverse determination in accordance with paragraph 8.2.a.8; and

8.2.a.10. A statement explaining the availability of and the right of the covered person, as appropriate, to contact the Commissioner's office at any time for assistance or, upon completion of the issuer's grievance procedures process as provided under W.Va. Code of St. R. § 114-96-1et seq., to file a civil suit in a court of competent jurisdiction. The statement shall include contact information for the Commissioner's office.

8.2.b. An issuer shall provide the notice required under this section in a culturally and linguistically appropriate manner in accordance with subdivision 7.3.b.

8.2.c. If the adverse determination is a rescission, the issuer shall provide, in addition to any applicable disclosures required under subdivision 8.2.a, the disclosures set forth in subdivision 7.3.c:

8.2.d.. An issuer may provide the notice required under this section orally, in writing or electronically. If notice of the adverse determination is provided orally, the issuer shall provide written or electronic notice of the adverse determination within three days following the oral notification.

W. Va. Code R. § 114-95-8