§33-25C-5 Enrollee complaints; internal grievance procedure.
§33-25C-5. Enrollee complaints; internal grievance procedure.
(a) Each managed care plan must establish and maintain an internal grievance procedure for the fair consideration of disputes relating to any provisions of the plan's contract, including, but not limited to, claims regarding the scope of coverage for health care services; denials, cancellations or nonrenewals of enrollee coverage; observance of an enrollee's rights as a patient; the quality of health care services; or decisions by managed care plans to deny, modify, reduce, or terminate coverage of or payment for health care services for an enrollee, as more specifically set forth in section twelve, article twenty-five-a, chapter thirty-three of this code.
(b) Except for determinations of whether a health care service is medically necessary, or determinations of whether a health care service is experimental, an enrollee may appeal the final decision resulting from the internal grievance procedure to the insurance commissioner, as set forth in section twelve, article twenty-five-a, chapter thirty-three of this code.
(c) Any party aggrieved by an order of the insurance commissioner may appeal to the circuit court of Kanawha County, as set forth in section fourteen, article two, chapter thirty-three. The judgment of the circuit court may be reviewed upon appeal by the supreme court of appeals in the same manner as other civil cases to which the state is a party.