A. Each utilization review entity subject to this article shall adopt a utilization review plan that contains procedures for complying with the requirements and standards of § 32.1-137.9 and other applicable provisions of this article. Such plan shall contain, at a minimum, the following:
1. Specific procedures to be used in review determinations, including an expedited review of no more than twenty-four hours for review determinations relating to prescriptions for the alleviation of cancer pain;
2. A provision for advance notice to covered persons of any requirements for certification of the health care setting or pre-approval of the necessity of health care service or any other prerequisites to approval of payment;
3. A provision for advance notice to covered persons that compliance with the review process is not a guarantee of benefits or payment under the health benefit plan;
4. A provision for a process for reconsideration of adverse decisions in accordance with § 32.1-137.14 and an appeals process in accordance with § 32.1-137.15; and
5. Policies and procedures designed to ensure confidentiality of patient-specific medical records and information in accordance with subsection C of § 32.1-137.12.
B. Each utilization review entity subject to this chapter shall make available to providers and covered persons, upon written request, a copy of those portions of its utilization review plan relevant to the specific request.
C. The Commissioner shall have the right to determine that an entity has complied with the requirement that the entity adopt a utilization review plan in accordance with subsection A.
1998, c. 891; 1999, c. 857.
Structure Code of Virginia
Chapter 5 - Regulation of Medical Care Facilities and Services
§ 32.1-125.01. Failing to report; penalty
§ 32.1-125.1. Inspection of hospitals by state agencies generally
§ 32.1-125.2. Disclosure of other providers of services
§ 32.1-125.4. Retaliation or discrimination against complainants
§ 32.1-125.5. Confidentiality of complainant's identity
§ 32.1-126.02. Hospital pharmacy employees; criminal records check required
§ 32.1-126.1. Asbestos inspection for hospitals
§ 32.1-126.2. Fire suppression systems required in nursing facilities and nursing homes
§ 32.1-126.3. Fire suppression systems required in hospitals
§ 32.1-126.4. Hospital standing orders or protocols for certain vaccinations
§ 32.1-126.5. Consolidation of inspections
§ 32.1-127.01. Regulations to authorize certain sanctions and guidelines
§ 32.1-127.1. Immunity from liability for routine referral for organ and tissue donation
§ 32.1-127.1:01. Record storage
§ 32.1-127.1:03. Health records privacy
§ 32.1-127.1:04. Use or disclosure of certain protected health information required
§ 32.1-127.1:05. Breach of medical information notification
§ 32.1-127.3. Immunity from liability for certain free health care services
§ 32.1-128. Applicability to hospitals and nursing homes for practice of religious tenets
§ 32.1-129. Application for license
§ 32.1-131. Expiration and renewal of licenses
§ 32.1-133. Display of license
§ 32.1-133.1. Human trafficking hotline; posted notice required; civil penalty
§ 32.1-134. Family planning information in hospitals providing maternity care
§ 32.1-134.01. Certain information required for maternity patients
§ 32.1-134.02. Infants; blood sample provided to parents
§ 32.1-134.2. Clinical privileges for certain practitioners
§ 32.1-134.3. Response to applications for clinical privileges
§ 32.1-134.4. Right of podiatrists or nurse practitioners to injunction
§ 32.1-135.1. Certain advertisements prohibited
§ 32.1-135.2. Offer or payment of remuneration in exchange for referral prohibited
§ 32.1-136. Violation; penalties
§ 32.1-137. Certification of medical care facilities under Title XVIII of Social Security Act
§ 32.1-137.01. Posting of charity care policies
§ 32.1-137.02. Hospital discharge procedures
§ 32.1-137.03. Discharge planning; designation of individual to provide care
§ 32.1-137.04. Patient notice of observation or outpatient status
§ 32.1-137.06. Lyme disease test result information
§ 32.1-137.07. Violations of certain provisions; penalty
§ 32.1-137.08. Medical care facilities; persons with disabilities; designated support persons
§ 32.1-137.09. Hospital emergency department CPT code data reporting
§ 32.1-137.010. Financial assistance; payment plans
§ 32.1-137.2. Certification of quality assurance; application; issuance; denial; renewal
§ 32.1-137.4. Examination, review or investigation
§ 32.1-137.6. Complaint system
§ 32.1-137.8. Application to and compliance by utilization review entities
§ 32.1-137.9. Requirements and standards for utilization review entities
§ 32.1-137.10. Utilization review plan required
§ 32.1-137.11. Accessibility of utilization review entity
§ 32.1-137.13. Adverse determination
§ 32.1-137.14. Reconsideration of adverse determination
§ 32.1-137.15. Adverse determination; appeal
§ 32.1-137.17. Limitation on Commissioner's jurisdiction
§ 32.1-138.1. Implementation of transfer and discharge policies
§ 32.1-138.2. Certain contract provisions prohibited
§ 32.1-138.3. Third party guarantor prohibition
§ 32.1-138.4. Retaliation or discrimination against complainants
§ 32.1-138.5. Confidentiality of complainant's identity
§ 32.1-138.7. Certificates of registration required; issuance; transferability; regulations
§ 32.1-138.8. Consultation with health regulatory boards
§ 32.1-138.9. Standards for approval
§ 32.1-138.10. Expiration; renewal
§ 32.1-138.11. Denial; revocation
§ 32.1-138.12. Waiver of requirements of article
§ 32.1-138.13. Access to and confidentiality of patient-specific medical records and information
§ 32.1-138.14. No private right of action created
§ 32.1-162.2. Exemptions from article
§ 32.1-162.3. License required for hospice programs; notice of denial of license; renewal thereof
§ 32.1-162.5:1. Notice to dispenser of patient's death; disposition of dispensed drugs
§ 32.1-162.6. Revocation or suspension of license
§ 32.1-162.6:1. Possession or administration of cannabis oil
§ 32.1-162.8. Exemptions from article
§ 32.1-162.9. Licenses required; renewal thereof
§ 32.1-162.10. Inspections; fees
§ 32.1-162.11. Liability insurance required
§ 32.1-162.13. Revocation or suspension of license
§ 32.1-162.15. Violation; penalties
§ 32.1-162.15:1. Unlawful advertising as a home care organization
§ 32.1-162.15:2. (Effective July 1, 2023) Definitions
§ 32.1-162.15:3. (Effective July 1, 2023) Services for survivors of sexual assault; plan required
§ 32.1-162.15:4. (For effective date, see Acts 2020, c 725) Treatment services
§ 32.1-162.15:5. Transfer services
§ 32.1-162.15:7. (Effective July 1, 2023) Inspections; report required
§ 32.1-162.15:9. (Effective July 1, 2023) Submission of evidence
§ 32.1-162.15:10. (Effective July 1, 2023) Complaints
§ 32.1-162.15:11. Task Force on Services for Survivors of Sexual Assault