Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. The description shall include a statement that informs the covered person of his right to file a request for an external review of an adverse determination or final adverse determination with the Commission. The statement shall explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. The statement shall include the telephone number and address of the Commission. The statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
2011, c. 788.
Structure Code of Virginia
Chapter 35.1 - Health Carrier Internal Appeal Process and External Review
§ 38.2-3558. Health carrier's internal appeal process
§ 38.2-3559. Notice of right to external review
§ 38.2-3560. Exhaustion of internal appeal process
§ 38.2-3561. Standard external review
§ 38.2-3562. Expedited external review
§ 38.2-3563. External review of experimental or investigational treatment adverse determinations
§ 38.2-3564. Binding nature of external review decision
§ 38.2-3565. Minimum qualifications for independent review organizations
§ 38.2-3566. Approval of independent review organizations
§ 38.2-3567. Independent review organizations to be held harmless
§ 38.2-3568. External review reporting requirements
§ 38.2-3569. Funding of external review