West Virginia Code 33-45-8 – Exemptions
(a) The provisions of this article do not apply to claims that are not covered under the terms of the health plan.
Terms Used In West Virginia Code 33-45-8
- Claim: means each individual request for reimbursement or proof of loss made by or on behalf of an insured or a provider to an insurer, or its intermediary, administrator or representative, with which the provider has a provider contract for payment for health care services under any health plan. See West Virginia Code 33-45-1
- Health plan: means any individual or group health care plan, subscription contract, evidence of coverage, certificate, health services plan. See West Virginia Code 33-45-1
- Insured: means a person who is provided health insurance coverage or other health care services coverage from an insurer under a health plan. See West Virginia Code 33-45-1
- Insurer: means any person required to be licensed under this chapter which offers or administers as a third party administrator health insurance. See West Virginia Code 33-45-1
- Provider: means a person or other entity which holds a valid license or permit, including a valid temporary license or permit pursuant to chapter 30 of this code, to provide specific health care services in this state. See West Virginia Code 33-45-1
- State: when applied to a part of the United States and not restricted by the context, includes the District of Columbia and the several territories, and the words "United States" also include the said district and territories. See West Virginia Code 2-2-10
(b) Nothing in this article shall preclude the right of a provider or insurer to pursue any other administrative, civil or criminal proceedings or remedies permitted under state or federal law.
(c) The provisions of this article do not apply when there is a good faith dispute about the legitimacy of amount of the claim, or when there is a reasonable basis supported by specific information that such claim was submitted fraudulently or with material misrepresentation.
(d) An insurer shall not be considered to be in violation of this article if the insurer's failure to comply is caused in material part by the person submitting the claim or the health insurer's compliance is rendered impossible due to matters beyond the insurer's reasonable control.
(e) A provider shall not be considered to be in violation of this article if the failure to comply is caused in material part by the insured or the provider's compliance is rendered impossible due to matters beyond the provider's reasonable control.
(f) The provisions of this article do not apply to services provided outside the state.