Terms Used In Virginia Code 32.1-137.15

• 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. See Virginia Code 32.1-137.7
• entity: means a person or entity performing utilization review. See Virginia Code 32.1-137.7
• Person: means an individual, corporation, partnership, or association or any other legal entity. See Virginia Code 32.1-3
• Process: includes subpoenas, the summons and complaint in a civil action, and process in statutory actions. See Virginia Code 1-237
• provider: means a licensed health care provider who renders or proposes to render health care services to a covered person. See Virginia Code 32.1-137.7