What is external review?
Independent external review is a second look at certain final denials by an OIC-certified independent review organization (IRO) that is not your insurance company.
West Virginia law gives you external review when services are denied as not medically necessary or experimental or investigational. For eligible cases, the IRO decision is binding on the issuer (W. Va. Code § 33-16H-3).
General overview: Appeals roadmap. Complete West Virginia internal appeals first unless deemed exhaustion or qualifying expedited review applies.
Who can use West Virginia review?
OIC external review under CSR 114-97 generally applies when:
- You have OIC-regulated commercial coverage (many HealthCare.gov and fully insured employer plans)
- The denial is based on medical necessity, appropriateness, level of care, effectiveness, or experimental/investigational treatment—not pure contractual exclusions or reimbursement-only disputes
- You exhausted internal grievance—or qualify for deemed exhaustion or simultaneous expedited review
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare, Medicaid, and TRICARE
- Dental-only, vision-only, and other non-health-plan products listed by OIC
Deadlines & exhaustion
Four months (CSR 114-97-6)
File a written external review request with the Commissioner within four months of receipt of an adverse determination or final adverse determination (CSR 114-97-6.1). Federal law also sets a minimum four-month window—do not wait.
Exhaust internal grievance first
Complete the issuer's internal grievance unless waived, you qualify for expedited simultaneous review, or you are deemed to have exhausted grievance when the issuer misses the 30-day written decision deadline without your agreement to delay (CSR 114-97-5.2).
Additional information to the IRO
After IRO assignment, you may submit additional information within 5 business days (standard) per CSR 114-97-6.5.a.
How to file
- Complete internal grievance and obtain a final adverse determination when required.
- Submit a written external review application and supporting documentation to the West Virginia Offices of the Insurance Commissioner at OICHealthPolicy@wv.gov (use forms and instructions on the OIC external review page).
- Include your final denial letter, insurance card copy, HIPAA authorization if requested, and clinical records.
- The Commissioner forwards your request to the issuer; the issuer must determine completeness/eligibility within 5 business days, then the Commissioner assigns a certified IRO.
OIC: External review process · Consumer help 888-879-9842
Links hub: West Virginia external appeals links.
How long it takes
- Standard review: IRO decision within 45 days after receipt of the external review request (CSR 114-97-6.8)
- Expedited review: within 72 hours after the IRO confirms eligibility (CSR 114-97-7.6); written confirmation within 48 hours
- Experimental/investigational: clinical reviewer opinions within 20 days; IRO decision within 20 days after opinions (CSR 114-97-8); expedited path within 48 hours
- Issuer must immediately approve coverage if the IRO reverses the denial
Is the decision binding?
For eligible disputes, the IRO decision is binding on the health issuer under W. Va. Code § 33-16H-3. If the IRO overturns the denial, the issuer must immediately approve the disputed service. You may have limited judicial review rights after a final adverse IRO decision—consult counsel for complex cases.
Medicaid & Medicare
Medicaid / Mountain Health Promise: Exhaust MCO internal appeal, then request a BMS state fair hearing within 120 days of the MCO decision (Bureau for Medical Services)—not OIC commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; free help from West Virginia SHIP.
More: Medicaid managed care · Medicare appeals.