§ 38.2-5901. Review by the Bureau of Insurance
A. A covered person or a treating health care provider, with the consent of the covered person, may appeal to the Bureau of Insurance for review of any final adverse decision in accordance with regulations promulgated by the Commission concerning a health service for which the actual cost to the covered person would exceed $300 if the final adverse decision is not reversed, determined in accordance with regulations adopted by the Commission. The appeal shall be filed within thirty days of the final adverse decision, shall be in writing on forms prescribed by the Bureau of Insurance, shall include a general release executed by the covered person for all medical records pertinent to the appeal, and shall be accompanied by a fifty-dollar filing fee. The fee shall be collected by the Bureau of Insurance and paid directly into the state treasury and credited to the fund for the maintenance of the Bureau of Insurance as provided in subsection B of § 38.2-400. The Bureau of Insurance may, for good cause shown, waive or refund the filing fee upon a finding that payment of the filing fee will cause undue financial hardship for the covered person or if the appeal is not accepted for review. The Bureau of Insurance shall provide a copy of the written appeal to the utilization review entity which made the final adverse decision.
B. The Bureau of Insurance or its designee shall conduct a preliminary review of the appeal to determine (i) whether the applicant is a covered person or a treating health care provider acting with the consent of the covered person, (ii) whether the benefit or service that is the subject of the application reasonably appears to be a covered service for which the actual cost to the covered person would exceed $300 if the final adverse decision is not reversed, (iii) whether all complaint and appeal procedures available under Article 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 have been exhausted, and (iv) whether the application is otherwise complete and filed in compliance with this section. Such preliminary review shall be conducted within ten working days of receipt of all information and documentation necessary to conduct a preliminary review. The Bureau of Insurance shall not accept for review any application which fails to meet the criteria set forth in this subsection. Within five working days of completion of the preliminary review, the Bureau of Insurance or its designee shall notify the applicant and the utilization review entity in writing whether the appeal has been accepted for review, and if not accepted, the reasons therefor.
C. The covered person, the treating health care provider, and the utilization review entity shall provide copies of the medical records relevant to the final adverse decision to the Bureau of Insurance within twenty working days after the Bureau of Insurance has mailed written notice of its acceptance of the appeal. Failure to comply with such request within twenty working days from the date of such request may result in dismissal of the appeal or reversal of the final adverse decision, in the discretion of the Commissioner or his designee. The confidentiality of such medical records shall be maintained in accordance with the confidentiality and disclosure laws of the Commonwealth. The Bureau of Insurance or its designee may, if deemed necessary, request additional medical records from the covered person, any treating health care provider or the utilization review entity. Failure to comply with such request within twenty working days from the date of such request may result in dismissal of the appeal or reversal of the final adverse decision in the discretion of the Commissioner or his designee.
D. The Commissioner or his designee, upon good cause shown, may provide an extension of time for the covered person, the treating health care provider, the utilization review entity and the Bureau of Insurance to meet the established time requirements set forth in this section.
(1999, cc. 643, 649; 2000, c. 922; 2001, c. 110; 2002, c. 745.)
Sections: Previous 38.2-5900 38.2-5901 38.2-5902 38.2-5903 38.2-5904 38.2-5905 NextLast modified: April 16, 2009