West Virginia Code 33-16H-2 – Issuer requirements
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An issuer shall, in accordance with rules promulgated pursuant to section four of this article, develop processes for utilization review and internal grievance procedures and shall make external review available with respect to all adverse determinations.
Terms Used In West Virginia Code 33-16H-2
- External review: means a review of a final adverse determination by an independent review organization. See West Virginia Code 33-16H-1
- issuer: means an entity required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including an accident and sickness insurance company, a health maintenance corporation, a health care corporation, a health or hospital service corporation, and a fraternal benefit society. See West Virginia Code 33-16H-1
- Utilization review: means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities. See West Virginia Code 33-16H-1