A. A treating provider may request reconsideration of an adverse determination pursuant to this section or may appeal an adverse determination pursuant to § 32.1-137.15. Any reconsideration of an adverse determination shall only be requested by the treating provider on behalf of the covered person. A determination on reconsideration shall be made by a physician advisor, peer of the treating health care provider, or a panel of other appropriate health care providers with at least one physician advisor or peer of the treating health care provider on the panel.
B. The treating provider on behalf of the covered person shall be (i) notified verbally at the time of the determination of the reconsideration of the adverse determination and in writing following the determination of the reconsideration of the adverse determination, in accordance with § 32.1-137.9, including the criteria used and the clinical reason for the adverse determination and the alternate length of treatment of the alternate treatment setting or settings, if any, that the entity deems to be appropriate, and (ii) notified verbally at the time of the determination of the reconsideration of the adverse determination of the process for an appeal of the determination pursuant to § 32.1-137.15 and the contact name, address, and telephone number to file and perfect an appeal. If the treating provider on behalf of the covered person requests that the adverse determination be reviewed by a peer of the treating provider at any time during the reconsideration process, the request for reconsideration shall be vacated and considered an appeal pursuant to § 32.1-137.15. In such cases, the covered person shall be notified that the reconsideration has been vacated and an appeal initiated, all documentation and information provided or relied upon during the reconsideration process pursuant to this section shall be converted to the appeal process, and no additional actions shall be required of the treating provider to perfect the appeal.
C. Any reconsideration shall be rendered and the determination provided to the treating provider and the covered person in writing within 10 working days of receipt of the request for reconsideration.
1998, c. 891; 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