                                 CODE OF VIRGINIA

NOTICE OF RIGHT TO EXTERNAL REVIEW (§ 38.2-3559)

A. A health carrier shall notify the covered person in writing of an adverse
determination or final adverse determination and the covered person&#8217;s
right to request an external review. The notice of the right to request an
external review shall include the following, or substantially similar, language:
&#8220;We have denied your request for the provision of or payment for a health
care service or course of treatment. You may have the right to have our decision
reviewed by health care professionals who have no association with us if our
decision involved making a judgment as to the medical necessity,
appropriateness, health care setting, level of care, or effectiveness of the
health care service or treatment you requested by submitting a request for
external review to the Commission.&#8221;

B. The notice of the right to request an external review of an adverse
determination shall include the following statements informing the covered
person that:

   1. If the covered person&#8217;s adverse determination involves (i) cancer or
   (ii) a medical condition where the time frame for completion of an expedited
   internal appeal of an adverse determination would seriously jeopardize the
   life or health of the covered person or would jeopardize the covered
   person&#8217;s ability to regain maximum function, the covered person or his
   authorized representative may file a request for an expedited external review
   pursuant to &#xA7; 38.2-3562;

   2. If the adverse determination involves a denial of coverage based on a
   determination that the recommended or requested health care service or
   treatment is experimental or investigational and the covered person&#8217;s
   treating physician certifies in writing that the recommended or requested
   health care service or treatment would be significantly less effective if not
   promptly initiated, the covered person or his authorized representative may
   file a request for an expedited external review pursuant to &#xA7; 38.2-3563;

   3. If the covered person or his authorized representative files a request for
   an expedited internal appeal with the health carrier, he may file at the same
   time a request for an expedited external review of an adverse determination
   pursuant to &#xA7; 38.2-3562 or 38.2-3563. The independent review organization
   assigned to conduct the expedited external review will determine whether the
   covered person shall be required to complete the expedited internal appeal
   prior to conducting the expedited external review; and

   4. If the covered person or his authorized representative files a standard
   appeal with the health carrier&#8217;s internal appeal process, and the health
   carrier does not issue a written decision within 30 days following the date
   the appeal requesting a review is filed and the covered person or his
   authorized representative did not request or agree to a delay, the covered
   person or his authorized representative may file a request for external review
   and shall be considered to have exhausted the health carrier&#8217;s internal
   appeal process.

C. The notice of the right to request an external review of a final adverse
determination shall include the following statements informing the covered
person that:

   1. If the covered person has a medical condition where the time frame for
   completion of a standard external review would seriously jeopardize the life
   or health of the covered person or would jeopardize the covered person&#8217;s
   ability to regain maximum function, the covered person or his authorized
   representative may file a request for an expedited external review pursuant to
   &#xA7; 38.2-3562;

   2. If the final adverse determination involves an admission, availability of
   care, continued stay, or health care service for which the covered person
   received emergency services, but has not been discharged from a facility, the
   covered person or his authorized representative may request an expedited
   external review pursuant to &#xA7; 38.2-3562; and

   3. If the final adverse determination involves a denial of coverage based on a
   determination that the recommended or requested health care service or
   treatment is experimental or investigational, the covered person or his
   authorized representative may file a request for a standard external review
   pursuant to &#xA7; 38.2-3563; or if the covered person&#8217;s treating
   physician certifies in writing that the recommended or requested health care
   service or treatment would be significantly less effective if not promptly
   initiated, the covered person or his authorized representative may request an
   expedited external review pursuant to subsection B of &#xA7; 38.2-3563.

D. The health carrier shall include the standard and expedited external review
procedures and any forms with the notice of the right to an external review.

HISTORY: 2011, c. 788; 2019, cc. 826, 840.