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1999 SESSION

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HB 2353 Health insurance; review of adverse utilization review decisions.

Introduced by: John J. Davies III | all patrons    ...    notes | add to my profiles

SUMMARY AS INTRODUCED:

Review of adverse utilization review decisions; review of claims appeal by an independent external panel; penalty. Establishes, within the State Corporation Commission’s Bureau of Insurance, a process of independent external review for individuals denied a course of treatment by their managed care health insurance plan. If the person seeking review is determined by the Bureau of Insurance (i) to have coverage by the health plan, (ii) to be seeking a treatment that appears to be covered by the plan, (iii) to have exhausted all available utilization review complaint and appeals procedures and (iv) to have provided all information necessary to begin review, an impartial appeals panel comprised of one representative from a licensee operating a managed care health insurance plan not involved in the complaint, one health care practitioner (selected by the individual who submitted the appeal from a list of three practitioners compiled by the Board of Medicine and selected by the State Corporation Commission) and the Commissioner of Insurance or his designee.. Each individual seeking such review will pay a filing fee of $50, which is returned if the covered person prevails as a result of the review. Insurers writing accident and sickness insurance in Virginia will pay an assessment not to exceed 0.01 percent of the direct gross premium income during the preceding year to fund such appeals. The State Corporation Commission will also promulgate regulations implementing the provisions of this bill, including establishing provisions for expedited consideration of appeals involving emergency health care. Any managed care health insurance plan that does not comply within 10 working days after receipt of notification of a decision by the External Appeals Panel shall be subject to, in addition to other penalties currently in Title 38.2, an additional penalty of $500 per day noncompliance with the decision of the External Appeals Panel. Managed care health insurance plans are required to include information about the External Appeals Panel in their complaint procedures, as well as to provide information about this process anytime an adverse utilization review decision is communicated to a covered person. The bill’s provisions become effective on July 1, 1999; however, the appeals process set forth in the bill does not take effect until the earlier of (i) 90 days following the promulgation of regulations by the State Corporation Commission or (ii) July 1, 2000.


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