§33-25C-6 External review of health care disputes. - West Virginia Statutes

§33-25C-6. External review of health care disputes.
(a) For determinations of whether a health care service is medically necessary, or determinations of whether a health care service is experimental, an enrollee may seek review by a certified external review organization of a managed care plan's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service, after exhausting the managed care plan's internal grievance process and receiving a decision that is unfavorable to the enrollee, or after the managed care plan has exceeded the time periods for grievances provided in section twelve, article twenty-five-a of this chapter, without good cause and without reaching a decision.

(b) A request for external review must be made in writing to the managed care plan and the insurance commissioner, within sixty days after the managed care plan has exceeded the time periods for grievances without reaching a decision, as set forth in subsection (a) of this section, or within sixty days after receiving an unfavorable decision by the managed care plan.

(c) External reviews may be requested by enrollees where the denial, reduction, modification or termination of payment for health care services for an enrollee would result in payment of at least one thousand dollars or a course of health care services that would exceed one thousand dollars by the enrollee if the health care were paid for by the enrollee.

(d) In an external review, the external review organization must consider, at a minimum, the information submitted by the managed care plan, the enrollee and the enrollee's provider, including the enrollee's medical records; the terms and conditions of the plan; and the standards, criteria and clinical rationale used by the managed care plan to reach its decision.

(e) External reviews relate only to questions of whether a health care service is medically necessary or whether a health care service is experimental. The cost of external reviews shall be borne by the managed care plan.

(f) Determinations of whether a health care service is medically necessary will be made by an external review organization through use of at least one physician, or other provider appropriate to the health care service under consideration, who is knowledgeable about the recommended or requested health service.

(g) Determinations of whether a health care service is experimental will be made by an external review organization through use of a panel of at least three physicians, or other providers appropriate to the health care service under consideration, who are knowledgeable about the recommended or requested health service.

(h) External reviews which relate to both a determination of whether a health care service is medically necessary and a determination of whether a health care service is experimental will be conducted by a panel of at least three physicians, or other providers appropriate to the health care service under consideration, who are knowledgeable about the recommended or requested health service.

(i) Questions of coverage of health care services which do not include determinations of whether a health care service is medically necessary or whether a health care service is experimental will be confined to the internal grievance procedure as referenced in section five of this article and set forth in section twelve, article twenty-five-a of this chapter, and in the rules of the insurance commissioner.

(j) Failure of the managed care plan to make all reasonable efforts to provide medical and other relevant records to the external review organization within the time frames set by the commissioner will result in a determination in the external review adverse to the managed care plan, in which event the managed care plan must provide coverage for the requested or proposed health care services.

(k) Failure of the enrollee to provide medical and other relevant records to the external review organization within the time frames established by the commissioner will result in the external review proceeding to decision without consideration of the records in the possession or control of the enrollee.

(l) Upon written request, the commissioner may grant additional time, for good cause shown, in which a party may forward records to the external review organization if the party has made a timely request to the provider to forward the records, and the provider has failed to forward the records as requested. If the external review is an expedited review, the commissioner must consider the possible adverse health consequences to the enrollee in determining whether to permit additional time to comply.

(m) Either the managed care plan or the enrollee may request that the commissioner issue subpoenas to providers for the enrollee's medical or other relevant records.

(n) Upon an enrollee's request, an expedited external review shall be provided within a period of seven days in circumstances where failure of the enrollee to immediately receive the requested or proposed health care service could result in placing the health of the enrollee or the health of enrollee's unborn child in serious jeopardy, cause serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. The commissioner may, by rule, shorten the seven-day time frame.

(o) The commissioner shall propose rules in accordance with section nine of this article which establish procedures for external reviews under this article and certification of external review organizations. In development of these rules, the commissioner shall consider the latest version of the national association of insurance commissioners health carrier external review model act. These rules shall provide:

(1) The maximum rates and maximum amounts which external review organizations may charge for external reviews;

(2) Procedures for the fair and efficient selection of and assignment of external review organizations to external reviews as they are requested;

(3) Procedures and specific time constraints for the provision of the enrollee's medical and other relevant records to the external review organization upon the occurrence of an external review; (4) Specified time frames within which the managed care plan and the enrollee must provide all medical and similar records to the external review organization;

(5) Provisions for the confidentiality of enrollee medical records;

(6) Procedures and standards to insure that external review organizations are properly qualified and approved by the commissioner to perform external reviews; and

(7) Procedures for fair notice to the enrollee and the managed care plan of decisions or other important steps in the external review process.

(p) Upon written application to and approval by the commissioner, a managed care plan may be exempted from the requirements for external review as specified in this section upon a showing that:

(1) The managed care plan has an established external review procedure in place;

(2) The managed care plan has been reviewed by and maintains a current full accreditation from a nationally recognized accreditation and review organization approved by the commissioner, in accordance with section seventeen-a, article twenty-five-a of this chapter; and

(3) As part of the accreditation process the accreditation and review organization reviewed and approved the managed care plan's external review process.