A. A covered person or a treating health care provider, with the consent ofthe covered person, may appeal to the Bureau of Insurance for review of anyfinal adverse decision in accordance with regulations promulgated by theCommission concerning a health service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, determined in accordance with regulations adopted by theCommission. The appeal shall be filed within thirty days of the final adversedecision, shall be in writing on forms prescribed by the Bureau of Insurance,shall include a general release executed by the covered person for allmedical records pertinent to the appeal, and shall be accompanied by afifty-dollar filing fee. The fee shall be collected by the Bureau ofInsurance and paid directly into the state treasury and credited to the fundfor 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 orrefund the filing fee upon a finding that payment of the filing fee willcause undue financial hardship for the covered person or if the appeal is notaccepted for review. The Bureau of Insurance shall provide a copy of thewritten appeal to the utilization review entity which made the final adversedecision.
B. The Bureau of Insurance or its designee shall conduct a preliminary reviewof the appeal to determine (i) whether the applicant is a covered person or atreating health care provider acting with the consent of the covered person,(ii) whether the benefit or service that is the subject of the applicationreasonably appears to be a covered service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, (iii) whether all complaint and appeal procedures available underArticle 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 have beenexhausted, and (iv) whether the application is otherwise complete and filedin compliance with this section. Such preliminary review shall be conductedwithin ten working days of receipt of all information and documentationnecessary to conduct a preliminary review. The Bureau of Insurance shall notaccept for review any application which fails to meet the criteria set forthin this subsection. Within five working days of completion of the preliminaryreview, the Bureau of Insurance or its designee shall notify the applicantand the utilization review entity in writing whether the appeal has beenaccepted for review, and if not accepted, the reasons therefor.
C. The covered person, the treating health care provider, and the utilizationreview entity shall provide copies of the medical records relevant to thefinal adverse decision to the Bureau of Insurance within twenty working daysafter the Bureau of Insurance has mailed written notice of its acceptance ofthe appeal. Failure to comply with such request within twenty working daysfrom the date of such request may result in dismissal of the appeal orreversal of the final adverse decision, in the discretion of the Commissioneror his designee. The confidentiality of such medical records shall bemaintained in accordance with the confidentiality and disclosure laws of theCommonwealth. The Bureau of Insurance or its designee may, if deemednecessary, request additional medical records from the covered person, anytreating health care provider or the utilization review entity. Failure tocomply with such request within twenty working days from the date of suchrequest may result in dismissal of the appeal or reversal of the finaladverse decision in the discretion of the Commissioner or his designee.
D. The Commissioner or his designee, upon good cause shown, may provide anextension of time for the covered person, the treating health care provider,the utilization review entity and the Bureau of Insurance to meet theestablished time requirements set forth in this section.
(1999, cc. 643, 649; 2000, c. 922; 2001, c. 110; 2002, c. 745.)
A. A covered person or a treating health care provider, with the consent ofthe covered person, may appeal to the Bureau of Insurance for review of anyfinal adverse decision in accordance with regulations promulgated by theCommission concerning a health service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, determined in accordance with regulations adopted by theCommission. The appeal shall be filed within thirty days of the final adversedecision, shall be in writing on forms prescribed by the Bureau of Insurance,shall include a general release executed by the covered person for allmedical records pertinent to the appeal, and shall be accompanied by afifty-dollar filing fee. The fee shall be collected by the Bureau ofInsurance and paid directly into the state treasury and credited to the fundfor 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 orrefund the filing fee upon a finding that payment of the filing fee willcause undue financial hardship for the covered person or if the appeal is notaccepted for review. The Bureau of Insurance shall provide a copy of thewritten appeal to the utilization review entity which made the final adversedecision.
B. The Bureau of Insurance or its designee shall conduct a preliminary reviewof the appeal to determine (i) whether the applicant is a covered person or atreating health care provider acting with the consent of the covered person,(ii) whether the benefit or service that is the subject of the applicationreasonably appears to be a covered service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, (iii) whether all complaint and appeal procedures available underArticle 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 have beenexhausted, and (iv) whether the application is otherwise complete and filedin compliance with this section. Such preliminary review shall be conductedwithin ten working days of receipt of all information and documentationnecessary to conduct a preliminary review. The Bureau of Insurance shall notaccept for review any application which fails to meet the criteria set forthin this subsection. Within five working days of completion of the preliminaryreview, the Bureau of Insurance or its designee shall notify the applicantand the utilization review entity in writing whether the appeal has beenaccepted for review, and if not accepted, the reasons therefor.
C. The covered person, the treating health care provider, and the utilizationreview entity shall provide copies of the medical records relevant to thefinal adverse decision to the Bureau of Insurance within twenty working daysafter the Bureau of Insurance has mailed written notice of its acceptance ofthe appeal. Failure to comply with such request within twenty working daysfrom the date of such request may result in dismissal of the appeal orreversal of the final adverse decision, in the discretion of the Commissioneror his designee. The confidentiality of such medical records shall bemaintained in accordance with the confidentiality and disclosure laws of theCommonwealth. The Bureau of Insurance or its designee may, if deemednecessary, request additional medical records from the covered person, anytreating health care provider or the utilization review entity. Failure tocomply with such request within twenty working days from the date of suchrequest may result in dismissal of the appeal or reversal of the finaladverse decision in the discretion of the Commissioner or his designee.
D. The Commissioner or his designee, upon good cause shown, may provide anextension of time for the covered person, the treating health care provider,the utilization review entity and the Bureau of Insurance to meet theestablished time requirements set forth in this section.
(1999, cc. 643, 649; 2000, c. 922; 2001, c. 110; 2002, c. 745.)
A. A covered person or a treating health care provider, with the consent ofthe covered person, may appeal to the Bureau of Insurance for review of anyfinal adverse decision in accordance with regulations promulgated by theCommission concerning a health service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, determined in accordance with regulations adopted by theCommission. The appeal shall be filed within thirty days of the final adversedecision, shall be in writing on forms prescribed by the Bureau of Insurance,shall include a general release executed by the covered person for allmedical records pertinent to the appeal, and shall be accompanied by afifty-dollar filing fee. The fee shall be collected by the Bureau ofInsurance and paid directly into the state treasury and credited to the fundfor 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 orrefund the filing fee upon a finding that payment of the filing fee willcause undue financial hardship for the covered person or if the appeal is notaccepted for review. The Bureau of Insurance shall provide a copy of thewritten appeal to the utilization review entity which made the final adversedecision.
B. The Bureau of Insurance or its designee shall conduct a preliminary reviewof the appeal to determine (i) whether the applicant is a covered person or atreating health care provider acting with the consent of the covered person,(ii) whether the benefit or service that is the subject of the applicationreasonably appears to be a covered service for which the actual cost to thecovered person would exceed $300 if the final adverse decision is notreversed, (iii) whether all complaint and appeal procedures available underArticle 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 have beenexhausted, and (iv) whether the application is otherwise complete and filedin compliance with this section. Such preliminary review shall be conductedwithin ten working days of receipt of all information and documentationnecessary to conduct a preliminary review. The Bureau of Insurance shall notaccept for review any application which fails to meet the criteria set forthin this subsection. Within five working days of completion of the preliminaryreview, the Bureau of Insurance or its designee shall notify the applicantand the utilization review entity in writing whether the appeal has beenaccepted for review, and if not accepted, the reasons therefor.
C. The covered person, the treating health care provider, and the utilizationreview entity shall provide copies of the medical records relevant to thefinal adverse decision to the Bureau of Insurance within twenty working daysafter the Bureau of Insurance has mailed written notice of its acceptance ofthe appeal. Failure to comply with such request within twenty working daysfrom the date of such request may result in dismissal of the appeal orreversal of the final adverse decision, in the discretion of the Commissioneror his designee. The confidentiality of such medical records shall bemaintained in accordance with the confidentiality and disclosure laws of theCommonwealth. The Bureau of Insurance or its designee may, if deemednecessary, request additional medical records from the covered person, anytreating health care provider or the utilization review entity. Failure tocomply with such request within twenty working days from the date of suchrequest may result in dismissal of the appeal or reversal of the finaladverse decision in the discretion of the Commissioner or his designee.
D. The Commissioner or his designee, upon good cause shown, may provide anextension of time for the covered person, the treating health care provider,the utilization review entity and the Bureau of Insurance to meet theestablished time requirements set forth in this section.
(1999, cc. 643, 649; 2000, c. 922; 2001, c. 110; 2002, c. 745.)
