Before you can request an External Review you …

1 1 Before you can request an External Review you must havecompleted theinternal Review process provided by your insurance companyand received afinal TO External Review PROCESSWest Virginialaw gives you the right to an externalreviewwhenhealthcareservices aredenied by your insurer on thebasisthattheservices are notmedically necessary or that theservices are experimental or is anExternalReview? An externalreviewis a request that youmake to the state for anindependent Review of adenial of services by your insurer. Reviews are conducted by Independent ReviewOrganizations(IROs) that are certified bythe state and have a network of medical experts to Review your health insurer s denial ofservices. Youmust complete the attached application and submit the application and allsupporting documentation to theWest Virginia Offices of the InsuranceCommissionerto request an am Ieligiblefor anIndependentExternalReview?To be eligible foranindependent External Review , the following conditions must bemet: The service that is the subject of thereviewrequestmust be a covered benefit under theterms of your health insurance policy or at leastsomething thatcould be a coveredbenefit under certaincircumstances.

2 Unless youmeet the standardfor expedited External Review (see below), youmust havecompleted the internalreviewprocess providedby your insurer and received a finaldecision from your , this requirement need not bemet if your insureragrees in writing to submit its decision toanindependent External Review prior tocompletion oftheinternal addition, if you have requestedan internal reviewfrom your insurance company and have not received a decision from your insurer withintherequired time frames, youmay proceed toanexternal Review without havingreceived a final decision from your insurerconcerning theinternal if you2meet the standard foranexpedited External Review , youmust continue to pursue allinternalreviewoptions available to you while simultaneously proceeding withanexpedited External Review . Youmust submit your request foranindependent External Review to theWest VirginiaOffices of the Insurance Commissionerwithin 180 days of the date that youwere firsteligible torequest areview.

3 Normally, this will be thedate ofthe health insurer swritten,final denial decision ontheinternal Review . Your request for anindependent externalreviewmust not be for the purpose ofpursuing a claimor allegation of healthcare providermalpractice, professionalnegligence, or other professional there typesof health insurance for whichExternalReview isNOTavailable?In general,anindependent External Review isavailable formost health insurance , service denials relating to the following typesof insurance coverage or healthbenefit programs are not reviewable underWest Virginia sexternal Review law: Medicaid, theWest VirginiaChildren s Health Insurance Program(CHIP), Medicare, orservices provided under these programs but through a contracted health insurer. All other government-sponsored health insurance or health servicesprograms. Healthbenefit plans that are self-funded by someone else represent me in my External Review ?Yes, youmay designate anyone you would like, including your treating health care provider,to represent you.

4 To do so, youmustfill out the section of the externalreviewrequest formentitled Appointment of Authorized Representative. Youmay revoke this authorization atany do I request an External Review ?Youmay request an independent External Review byfillingout theattached RequestforIndependentExternalAppealofa Healthcare Decision form and submitting it to theWestVirginia Offices of the Insurance Commissionertogether with the required supportingdocumentation. There is no cost toyou for anexternal be sure to include all of following with completed externalreviewrequest copy (if you received one) of theletter fromyour health insurer denying your requestat the final level of photocopy of your insurance card or other evidence that you are insured by the healthinsurance company named in yourexternalreviewrequest copy of your certificate of coverage or your insurance policy benefit booklet, whichlists your benefits, if records, statements from your treating health care providers, or otherinformation that you would like the independentrevieworganization to considerin reviewing your case, including lowerlevel call theOffices of the Insurance Commissionerat 304-558-3386,if you need helpwith the application, or if you do not have one or more of the above items and would likeinformation on alternative ways to completeyourrequestforindependentexterna l you are requesting a standardreview, send completed forms and all attachmentsto.

5 Independent External ReviewWest VirginiaOffices of the Insurance CommissionerPO Box 50540 Charleston, WV 25305-0540If you arerequesting an expeditedreview, call theOffices of the Insurance Commissioner(304-558-3386) Before sending your paperwork, and youwill receiveinstructionson thequickest way to submit the application and supporting is the standard Review process and time frame? Within 7 business days after receivingyour application form, theOffices of theInsurance Commissionerwill complete a preliminary Review to determine whether yourrequest is complete and whetheryour case iseligibleforanexternalreview. If therequest is not complete, theOffices of the Insurance Commissionerwill informyou oryour representative what information or documents are neededin order to will have10 days to supply the needed informationor documents. If the request for External Review isaccepted, theOffices of the InsuranceCommissionerwill selectand retain an independent Review organization to conductthe reviewand notify you and the insurer.

6 Within 10 days after receiving noticeof the acceptance of thereview, the insurermustprovide you and the selected independent revieworganization with all information initspossession that is relevant tothereview. If youwould like, you or yourrepresentative will then have 10more daysto submit new or additional information tothe independent Review organization. During this 10-day period you or yourrepresentativemay also present oral testimony via teleconference tothe independentreview organization and the insurer. However, oraltestimony will be permitted only incases where the Insurance Commissioner determines that it would not be feasible or4appropriate to present only written information. If you or your representative wouldlike to discuss your case with the independent Review organization and your insurer in atelephone conference, you can request this by checking the appropriate box intheexternalreviewrequest formor by contacting theOffices of the InsuranceCommissionerno later than 10 days after receiving notice ofthe acceptance of thereview.

7 At the end of this second 10-day period, the record of the case will be closed and nonew informationmay be submitted. The independent revieworganization will thenhave 20 days to Review all of the information and documents received, and render adecision upholding or reversing the determination of the do I request an Expedited External Review ?Because the standardprocess for handlinganexternal Review can take 45days, expedited(fast-tracked) External Review is available for those persons who would be significantlyharmed by having request an expedited Review by checking theappropriate box on thereviewrequestformand byhaving your treating health careprovidercomplete the certificationform that is attached to thereviewrequest form. Your health careprovidermust state that in theirmedical opinion adherence to the time frame for standardreview would seriouslyjeopardize your life or health or would jeopardizeyour abilitytoregainmaximum reviews must be completed in 72 you are pursuing an internalreviewwithyour insurer and anticipate that youmay berequesting an External Review on an expeditedbasis, please call theOffices of theInsuranceCommissionerat304-558-3386,i n advance, so that accommodations can bemade to receiveand process your request as quickly as happens when an Independent Review Organization makes itdecision?

8 If yourreviewwas expedited, inmost cases you and your health insurer will be notifiedof the independent Review organization sdecision immediately by telephone or notification willfollow. If yourreviewwas not expedited, you and your health insurerwill be notified in writing. The decision of the independent Review organization is binding on the health insurerand is enforceable by theWest VirginiaOffices of the Insurance Commissioner. Thedecision is binding on you as well,except that it does notprevent you frompursuingany other claimor remedy youmay have through the courts under federal or state you have any questions, please contact theWest Virginia Offices of theInsurance FOR INDEPENDENT External Review OF HEALTHCARE DECISIONENROLLEE INFORMATIONE nrollee s Name:_____ Patient s Name:_____Mailing Address:_____Email Address:_____Phone Numbers: Daytime (____)_____Evening (____)_____Enrollee s Insurance ID#:_____Insurance Claim/Reference #:_____INFORMATION ABOUT YOUR EMPLOYERE mployer s Name:_____Employer s Phone Number:_____Is the insurance you have through your employer a self-funded plan?

9 _____(If you are not certainplease check with your employer).INFORMATION ABOUT YOUR INSURANCE COVERAGEH ealth Insurance Company s Name:_____Insurer Mailing Address:_____Insurer Telephone Number: (____)_____Person at Health Insurance Company Involved with Your Appeal:_____INFORMATION ABOUT YOUR TREATING HEALTHCARE PROVIDERName of Healthcare Provider:_____Type of Provider: Medical Doctor or Other (please specify):_____Provider Mailing Address:_____Provider Phone Number: (____)_____2 APPOINTMENT OF AUTHORIZED REPRESENTATIVE(Fill out this section only if someone else will be representing you in this appeal.)You can represent yourself, or you may ask another person, including your treating healthcare provider, to act asyour personal representative. You may revoke this authorization at any hereby authorize _____ to pursue my appeal on my of Enrollee (or legal representative)*Date*(Parent, Guardian, Conservator, Attorney, or Other Please Specify):_____Address of Authorized Representative:_____Phone Numbers: Daytime (____)_____Evening (____)_____REQUEST FOR A TELEPHONE CONFERENCE(Fill out this section only ifyou would like to request a telephone conference.)

10 If you, your representative or your treating healthcare provider would like to discuss your case with theindependent Review organization and your insurer in a telephone conference, check the box below and explainwhy you think it is important to be allowed to speak about your case. If you do not request a telephoneconference, the reviewerwill base its decision on the written information only. Your request for a telephoneconference will be granted only if there is a good reason why the written information would not be , I want a phone conference. My reason for requesting a phone conference is that:_____HEALTH CARE DECISION IN DISPUTED escribe your health insurer s decision in your own words. Include any information you have about thehealthcare services, supplies or drugs being denied, including dates and names of healthcare providers. Explainwhy you disagree with the insurer. Attach additional pages if necessary. Also attach pertinent medical recordsand (if possible) a statement from your treating healthcare provider indicating why the disputed service, supply,or drug is medically REVIEWYou may request that your External appeal be handled on an expedited basis(see page 4).