W. Va. Code R. § 85-21-10

Current through Register Vol. XLI, No. 40, October 4, 2024

Section 85-21-10 - Minimum Grievance Standards

10.1. Each workers' compensation managed care plan shall contain an expeditious, informal grievance procedure to resolve disputes by employees and providers relative to the rendition of medical services. A detailed description of the employee grievance procedure shall be included in informational materials provided to employees and a detailed description of the provider grievance procedure shall be included in all provider contracts.

10.2. The grievance procedure shall meet the following minimum requirements:

a. Notice. A grievance is made when a written complaint or written request is delivered by the employee or provider to the managed health care system setting forth the nature of the complaint and remedial action requested.

b. Time frame to file grievance. The employee or provider shall file a grievance within thirty (30) days of the occurrence of the event giving rise to the dispute.

c. Resolution. The managed health care system shall render a written decision upon a grievance within thirty (30) days of receipt by the managed health care system of the grievance.

d. Arbitration. Managed care plans may provide for alternate means of dispute resolution including arbitration and mediation. In that event final resolution of a grievance shall not be subject to the time constraints set forth in paragraph c of this subsection. In all cases, resolution mechanisms shall be expeditious and where treatment matters are at issue reflect the need for prompt resolution.

10.3. Record of grievance proceedings. The managed health care plan shall maintain records for two (2) years of each formal grievance to include the following:

a. A description of the grievance; the employee's name and address; names and addresses of the health care providers relevant to the grievance; and the managed health care system's and employer's name and address; and

b. A description of the managed health care system's findings, conclusions, and disposition of the grievance.

10.4. Appeal. The managed health care plan shall notify the applicable self-insured employer, private carrier or the Commission of its final decision so that either the self-insured employer, private carrier or the Commission can issue a protestable order setting forth the decision. The Commission's or upon termination of the Commission, the insurance commissioner's, role is administrative only and it will not rule on the merits of the dispute. The time period set forth in the West Virginia Code to protest to the Office of Judges shall begin to run upon issuance of the protestable order and shall be tolled until that time.

W. Va. Code R. § 85-21-10