West Virginia Code Chapter 33. Insurance § 33-16H-1. Definitions

(1) “Adverse determination” means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other healthcare service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated.

(2) “External review” means a review of a final adverse determination by an independent review organization.

(3) “Final adverse determination” means an adverse determination that has been upheld by the issuer at the completion of the internal grievance procedures or an adverse determination with respect to which the internal grievance procedures have been deemed exhausted.

(4) “Health benefit plan” means a policy, contract, certificate or agreement entered into, offered or issued by an issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including short-term and catastrophic health insurance policies and policies that pay on a cost-incurred basis, but excludes the excepted benefits defined in 42 U. S. C. § 300gg-91 and policies, contracts, certificates or agreements excluded by rules promulgated pursuant to section four of this article.

(5) “Health plan issuer” or “issuer” means an entity required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including an accident and sickness insurance company, a health maintenance corporation, a health care corporation, a health or hospital service corporation, and a fraternal benefit society.

(6) “Independent review organization” means an entity approved by the commissioner to conduct external reviews of final adverse determinations.

(7) “Utilization review” means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities.