WVC 33 -
CHAPTER 33. INSURANCE.
WVC 33 - 15 B-
ARTICLE 15B. UNIFORM HEALTH CARE ADMINISTRATION ACT.
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§33-15B-1. Legislative findings; purpose.
The Legislature hereby finds that there is a need to provide
guidelines regarding uniform health care administration in order to
best serve consumers, health care providers and insurers and to
organize and streamline the claims process. The purpose of this
article is to authorize the Insurance Commissioner to develop
standard forms and procedures regarding health care claims and to
require that all insurers, third party payers, and health care
providers implement and use such standards in a uniform manner.
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§33-15B-2. Scope of article.
The provisions of this article apply to all health care
providers in the state; all health insurers writing or issuing
accident and sickness policies, including hospital service
corporations, health service corporations, medical service
corporations, dental service corporations and HMOs; all third party
payers; all state agencies and departments, including, but not
limited to, the public employees insurance agency and providers of
services under Medicare and Medicaid; and all entities involved in
the payment of health care claims.
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§33-15B-3. Insurance Commissioner to propose rules; use of
standardized forms and classifications; advisory
(a) The commissioner shall propose rules for legislative
approval, in accordance with the provisions of chapter
twenty-nine-a of this code, regarding the implementation and use of
uniform health care administrative forms. Such rules shall
establish, where practicable, the acceptance and use throughout the
health care system of standard administrative forms, terms or
procedures, including, but not limited to, the following:
(1) The standard CMS 1500 health insurance claim form, as
amended, or other similar forms, terms, and definitions to be used
which are consistent with health care and insurance industry
(2) International classification of disease, ninth clinical
modifications (ICD-9-CM) and common procedural terminology (CPT)
codes, as amended, or other similar forms, terms, and definitions
to be used which are consistent with health care and insurance
(3) National uniform billing data element specifications
(UB-04), as amended, and as supplemented by the West Virginia
uniform billing committee, or other similar forms, terms, and
definitions to be used which are consistent with health care and
insurance industry standards.
(4) Consideration of current practices involving reimbursement of claims and explanation of benefits, and the implementation of
standards and guidelines regarding explanation of benefits,
including, but not limited to, consideration of line item
explanations of payments or denial of payments.
(b) The legislative rules required herein shall be developed
with the advice of an advisory group to be appointed by the
commissioner. Such advisory group shall consist of representatives
of consumers, providers, payors, and regulatory agencies, including
representatives from the following: The department of health and
human resources; the West Virginia health care authority; West
Virginia dental association; West Virginia pharmacists association;
the West Virginia hospital association; commercial health insurers;
third party administrators; the West Virginia state medical
association; the West Virginia nurses association; public employees
insurance agency; and consumers.
(c) The commissioner and the advisory group shall review the
legislative rules to be proposed pursuant to this section as
necessary and update the same in a timely manner in order to
conform to current legislation and health care and insurance
industry standards and trends.
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Acts, 2010 Reg. Sess., Ch. 106.
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§33-15B-5. Penalties for violation.
Any person, partnership, corporation, limited liability
company, professional corporation, health care provider, insurer or
other payer, or other entity violating any provision of this
article shall be subject to a fine imposed by the commissioner of
not more than $1000 for each violation and, in addition to or in
lieu of any fine imposed, the West Virginia health care authority
is empowered to withhold rate approval or a certificate of need for
any health care provider violating any provision of this article.
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§33-15B-6. Citation of article.
This article may be known as the "Uniform Health Care