W. Va. Code R. § 85-21-8 - Suspension or Revocation of Certification

8.1. The certification of a managed care plan by the Commission or upon termination of the Commission, the insurance commissioner, may be suspended or revoked if:

a. Service is not being provided according to the terms of the certified managed care plan, or in accordance with prevailing treatment standards, or in accordance with treatment standards or practice parameters adopted by the Commission, or upon termination of the Commission, the insurance commissioner;

b. The plan for providing services or the contract with the insurer or health care provider fails to meet the requirements of the West Virginia Code or applicable state rules and regulations;

c. Any material false or misleading information is intentionally submitted by the managed health care system or participating provider to the Commission or upon termination of the Commission, the insurance commissioner, the employer, or the insurer;

d. The managed health care system knowingly or negligently utilizes a health care provider whose license, registration, or certification has been suspended or revoked, or who is otherwise ineligible to provide treatment of the type rendered to an injured employee; or

e. For any other good faith basis as determined in the sole discretion of the Commission or upon termination of the Commission, the insurance commissioner.

8.2. The Commission or upon termination of the Commission, the insurance commissioner, may investigate the operations of a certified managed health care plan at any time and the plan and its providers shall cooperate in any investigation by the Commission or upon termination of the Commission, the insurance commissioner. Should the Commission or upon termination of the Commission, the insurance commissioner, find that reasonable grounds for termination or suspension of a managed care plan certification exist, written notice setting forth those grounds shall be mailed to the system by certified mail, return receipt requested. The system is granted fifteen (15) days from the date of the verified receipt or refusal of the notice in which to file written response. Thereafter, the Commission or upon termination of the Commission, the insurance commissioner, shall render a written decision by which the certification of the plan may be terminated, suspended, or conditionally continued to permit the correction of deficiencies directed. The Commission's or upon termination of the Commission, the insurance commissioner's, decision is final and unappealable.

Notes

W. Va. Code R. § 85-21-8