Whom to contact:

West Virginia Insurance Commissioner and the managed care plan

Who can appeal:

You

What you can appeal

Managed care plan’s decision to deny, modify, reduce, or terminate coverage or payment for a health care service. External reviews relate only to questions of whether a health care service is medically necessary or whether a health care service is experimental, and the decision must involve services totaling $1,000 or more.

When you can appeal:

After exhausting your managed care plan’s internal grievance procedure, within 60 days of receiving an unfavorable decision by the managed care plan, or 60 days after the managed care plan has exceeded the time periods for grievances without reaching a decision.

What to send:

Request for external review form and release of medical records

What you must pay:

No charge

What will happen:

The Insurance Commissioner will notify the enrollee and the health maintenance organization of the internal review procedure within 7 days, after which the health maintenance organization and the enrollee must forward to the assigned external review organization all relevant documents and information in their possession.

When you will get a decision:

Decisions are due within 45 calendar days from the date of the request for external review. In expedited procedures, the decision must be made within 7 calendar days after the request is received by the Insurance Commissioner.

In urgent situations:

For decisions where delay would place the health of the enrollee or the health of the enrollee’s unborn child in serious jeopardy, an expedited review process is provided. For an expedited procedure, the Insurance Commissioner issues a notice within 2 business days and the health maintenance organization and the enrollee must respond with information within 2 business days. An expedited review produces a decision within 7 calendar days of the date the request for review is made.