Virginia Code 32.1-137.8: Application to and compliance by utilization review entities
A. No utilization review entity shall perform utilization review with regard to hospital, medical or other health care resources rendered or proposed to be rendered to a covered person except in accordance with the requirements and standards set forth in this article.
Terms Used In Virginia Code 32.1-137.8
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the State Department of Health. See Virginia Code 32.1-3
- 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
- plan: means a written procedure for performing review. See Virginia Code 32.1-137.7
- 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. See Virginia Code 32.1-137.7
B. This article shall not apply to utilization review performed under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act or under contract with a plan otherwise exempt from operation of this chapter pursuant to the Employee Retirement Income Security Act of 1974.
C. This article shall not apply to private review agents subject to Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia.
D. This article shall not apply to programs administered by the Department of Medical Assistance Services or under contract with the Department of Medical Assistance Services.