(a) If an insurer uses the services of an administrator, the insurer is responsible for determining the benefits, premium rates, underwriting criteria and claims payment procedures applicable to the coverage and for securing reinsurance, if any. The rules pertaining to these matters shall be provided, in writing, by the insurer to the administrator. The responsibilities of the administrator as to any of these matters shall be set forth in the written agreement between the administrator and the insurer.
(b) It is the sole responsibility of the insurer to provide for competent administration of its programs.
(c) In cases where an administrator administers benefits for more than one hundred certificate holders on behalf of an insurer, the insurer shall, at least semiannually, conduct a review of the operations of the administrator. At least one review shall be an on-site audit of the operations of the administrator.
(d) For purposes of this section, "insurer" means a licensed insurance company, prepaid hospital or medical care plan, health maintenance organization or a health care corporation.
Structure West Virginia Code
Article 46. Third-Party Administrator Act
§33-46-3. Written Agreement Necessary
§33-46-4. Payment to Administrator
§33-46-5. Maintenance of Information
§33-46-6. Approval of Advertising
§33-46-7. Responsibilities of the Insurer
§33-46-8. Premium Collection and Payment of Claims
§33-46-9. Compensation to the Administrator
§33-46-10. Notice to Covered Individuals; Disclosure of Charges and Fees
§33-46-11. Delivery of Materials to Covered Individuals
§33-46-12. Home State Certificate of Authority or License
§33-46-13. Registration Requirement
§33-46-14. Nonresident Administrator
§33-46-16. Annual Report and Filing Fee
§33-46-17. Grounds for Denial, Suspension or Revocation of License
§33-46-18. Exemption for Administrators of Public Health Programs