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1999 SESSION

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HB 2594 Review of adverse health utilization review decisions.

Introduced by: Harry R. Purkey | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED HOUSE:

Review of adverse utilization review decisions; review of claims appeal by an independent external panel. 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 to (i) have coverage by the health plan, (ii) be seeking a treatment that appears to be covered by the plan, (iii) have exhausted all available utilization review complaint and appeals procedures and (iv) have provided all information necessary to begin review, an impartial health entity shall review the final adverse decision to determine whether the decision is objective clinically valid, compatible with established principles of health care, and contractually appropriate. Each individual seeking such review will pay a filing fee of $50, which is nonrefundable. Insurers writing accident and sickness insurance in Virginia will pay an assessment not to exceed 0.015 percent of the direct gross premium income during the preceding year to fund such appeals process. The impartial health entity will issue a written recommendation within sixty days of the acceptance of the appeal by the Bureau of Insurance, and the State Corporation Commission will issue a binding order carrying out the recommendation of the impartial health entity. These appeals provisions become effective either (i) 90 days following the promulgation of regulations by the State Corporation Commission or (ii) July 1, 2000.

The bill also establishes an Office of Managed Care Ombudsman within the Bureau of Insurance. The Managed Care Ombudsman is charged with promoting and protecting the interests of covered persons under managed care health insurance plans in Virginia. The duties of the Managed Care Ombudsman include assisting persons in understanding their rights and processes available to them under their managed care plan, developing information on the types of managed health insurance plans available in Virginia, and monitoring and providing information to the General Assembly on managed care issues.

SUMMARY AS INTRODUCED:

Review of adverse utilization review decisions; review of claims appeal by an independent external panel. Establishes a process of independent external review for individuals denied a course of treatment by their managed care health plan. The treatment sought must cost more than $500, and the individual seeking review must pay a nonrefundable review fee of $50. If the person seeking review is determined by the Health Commissioner or his designee (i) to have coverage by the health plan, (ii) to be seeking a treatment that appears to be covered by the plan and costs more than $500, (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 health entity comprised of at least three individuals who are not related to or associated with the health plan being reviewed shall review the case. The Health Commissioner will issue a binding order affirming, modifying or reversing the decision of the health plan, based on a majority decision of the impartial health entity performing the review. The Board of Health will also promulgate regulations establishing (i) expedited appeals procedures for emergency situations, (ii) criteria and standards for eligible impartial health entities, and (iii) a schedule of fees to be paid by health plans upon conclusion of review.