                                 CODE OF VIRGINIA

EXHAUSTION OF INTERNAL APPEAL PROCESS (§ 38.2-3560)

A. A request for an external review shall not be made until the covered person
has exhausted the health carrier&#8217;s internal appeal process, provided that
a covered person&#8217;s exhaustion of the health carrier&#8217;s internal
appeal process shall not be required if the adverse determination relates to the
treatment of a cancer of the covered person.

B. A covered person shall be considered to have exhausted the health
carrier&#8217;s internal appeal process if the covered person or his authorized
representative has filed an appeal requesting a review of an adverse
determination, and, except to the extent the covered person or his authorized
representative requested or agreed to a delay, has not received a written
decision from the health carrier within 30 days following the date the appeal
was filed with the health carrier.

C. If a covered person or his authorized representative files a request for an
expedited internal appeal of an adverse determination with the health carrier,
the covered person or his authorized representative is deemed to have exhausted
the internal appeal process and may file a request for an expedited external
review of the adverse determination at the same time. Upon receipt of a request
for an expedited external review of an adverse determination, the independent
review organization conducting the external review shall determine whether the
covered person shall be required to complete the health carrier&#8217;s
expedited internal appeal process before it conducts the expedited external
review. The independent review organization shall promptly notify the covered
person and his authorized representative, if any, of this determination, and
either proceed with the expedited external review or wait until completion of
the internal expedited appeal process.

D. A request for an external review of an adverse determination may be made
before the covered person has exhausted the health carrier&#8217;s internal
appeal process whenever the health carrier agrees to waive the exhaustion
requirement. If the exhaustion requirement is waived, the covered person or his
authorized representative may file a request in writing for a standard external
review.

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