Utilization Review Licensing in West Virginia

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in West Virginia. For assistance with licensing, please contact us to learn about our software and managed license services.

West Virginia Health Insurance Independent Review Organization Certification

Type of Review:

Medical Utilization Review

Agency:West Virginia Offices of the Insurance Commissioner

Initial Registration

Agency:West Virginia Offices of the Insurance Commissioner
Form:

Independent Review Organization Application

Agency fee:

$0

Registration Renewal

Agency:West Virginia Offices of the Insurance Commissioner
Form:

Independent Review Organization Application (Renewal)

Agency fee:

$0

Due:

Biennially

West Virginia Long-Term Care Independent Review Organization Certification

Type of Review:

Medical Utilization Review

Agency:West Virginia Offices of the Insurance Commissioner

Initial Registration

Agency:West Virginia Offices of the Insurance Commissioner
Form:

Application for Certification in West Virginia as an IRO to Review Long-term Care Benefit-Trigger Determinations

Agency fee:

$0

Registration Renewal

Agency:West Virginia Offices of the Insurance Commissioner
Form:

Application for Certification in West Virginia as an IRO to Review Long-term Care Benefit-Trigger Determinations (Renewal)

Agency fee:

$0

Due:

Triennially

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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