As used in this article:
"Adverse determination" means a determination by the managed care health insurance plan or its designee utilization review entity that, based upon information provided, a request for a benefit upon application of any utilization review technique does not meet the managed care health insurance plan's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit. When the policy, contract, plan, certificate, or evidence of coverage includes coverage for prescription drugs and the health service rendered or proposed to be rendered is a prescription for the alleviation of cancer pain, any adverse determination shall be made within 24 hours of the request for coverage.
"Commission" means the Virginia State Corporation Commission.
"Covered person" means a subscriber, policyholder, member, enrollee or dependent, as the case may be, under a policy or contract issued or issued for delivery in Virginia by a managed care health insurance plan licensee, insurer, health services plan, or preferred provider organization.
"Evidence of coverage" includes any certificate, individual or group agreement or contract, or identification card or related documents issued in conjunction with the certificate, agreement or contract, issued to a subscriber setting out the coverage and other rights to which a covered person is entitled.
"Final adverse determination" means an adverse determination involving a covered benefit that has been upheld by a managed care health insurance plan, or its designee utilization review entity, at the completion of the managed care health insurance plan's internal appeal process.
"Medical director" means a physician licensed to practice medicine in the Commonwealth of Virginia who is an employee of a utilization review entity responsible for compliance with the provisions of this article.
"Peer of the treating health care provider" means a physician or other health care professional who holds a nonrestricted license in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
"Physician advisor" means a physician licensed to practice medicine in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States who provides medical advice or information to a private review agent or a utilization review entity in connection with its utilization review activities.
"Private review agent" means a person or entity performing utilization reviews, except that the term shall not include the following entities or employees of any such entity so long as they conduct utilization reviews solely for subscribers, policyholders, members or enrollees:
1. A health maintenance organization authorized to transact business in Virginia; or
2. A health insurer, hospital service corporation, health services plan or preferred provider organization authorized to offer health benefits in this Commonwealth.
"Treating health care provider" or "provider" means a licensed health care provider who renders or proposes to render health care services to a covered person.
"Utilization review" means a system for reviewing the necessity, appropriateness and efficiency of hospital, medical or other health care services rendered or proposed to be rendered to a patient or group of patients for the purpose of determining whether such services should be covered or provided by an insurer, health services plan, managed care health insurance plan licensee, or other entity or person. For purposes of this article, "utilization review" shall include, but not be limited to, preadmission, concurrent and retrospective medical necessity determination, and review related to the appropriateness of the site at which services were or are to be delivered. "Utilization review" shall not include (i) any review of issues concerning insurance contract coverage or contractual restrictions on facilities to be used for the provision of services, (ii) any review of patient information by an employee of or consultant to any licensed hospital for patients of such hospital, or (iii) any determination by an insurer as to the reasonableness and necessity of services for the treatment and care of an injury suffered by an insured for which reimbursement is claimed under a contract of insurance covering any classes of insurance defined in §§ 38.2-117, 38.2-118, 38.2-119, 38.2-124, 38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132, and 38.2-134.
"Utilization review entity" or "entity" means a person or entity performing utilization review.
"Utilization review plan" or "plan" means a written procedure for performing review.
1998, cc. 129, 891; 1999, c. 857; 2000, c. 564; 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