A. The treating provider shall be notified in writing of any adverse determination within two working days of the determination; however, the treating provider shall be notified orally by telephone within 24 hours of any adverse determination for a prescription known to be for the alleviation of cancer pain. Any such notification shall include instructions for the provider on behalf of the covered person to (i) seek a reconsideration of the adverse determination pursuant to § 32.1-137.14, including the contact name, address, and telephone number of the person responsible for making the adverse determination, and (ii) seek an appeal of the adverse determination pursuant to § 32.1-137.15, including the contact name, address, and telephone number to file and perfect such appeal.
B. No entity shall render an adverse determination unless it has made a good faith attempt to obtain information from the provider. At any time before the entity renders its determination, the provider shall be entitled to review the issue of medical necessity with a physician advisor or peer of the treating health care provider who represents the entity. For any adverse determination relating to a prescription to alleviate cancer pain, a physician advisor shall review the issue of medical necessity with the provider.
1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.
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