Terms Used In Virginia Code > Title 18.2 > Chapter 13 - Virginia Racketeer Influenced and Corrupt Organization Act

• Accident and sickness insurance: means insurance against loss resulting from sickness, or from bodily injury or death by accident or accidental means, or from a combination of any or all of these perils. See Virginia Code 38.2-109
• Adjourn: A motion to adjourn a legislative chamber or a committee, if passed, ends that day's session.
• Adverse determination: means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. See Virginia Code 38.2-3556
• Ambulatory review: means utilization review of health care services performed or provided in an outpatient setting. See Virginia Code 38.2-3556
• Assessment: as used in this subtitle , shall include an assessment made pursuant to notice by the Department of Taxation and self-assessments made by a taxpayer upon the filing of a return or otherwise not pursuant to notice. See Virginia Code 58.1-1820
• Authorized representative: means (i) a person to whom a covered person has given express written consent to represent the covered person in an external review, (ii) a person authorized by law to provide substituted consent for a covered person, or (iii) a family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent. See Virginia Code 38.2-3556
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Virginia Code 38.2-3556
• Best evidence: means evidence based on (i) randomized clinical trials; if randomized clinical trials are not available, then (ii) cohort studies or case-control studies; if clauses (i) and (ii) are not available, then (iii) case-series; or if clauses (i), (ii), and (iii) are not available, then (iv) expert opinion. See Virginia Code 38.2-3556
• Board of supervisors: means the governing body of a county. See Virginia Code 15.2-102
• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Virginia Code 38.2-3556
• Case-series: means an evaluation of a series of patients with a particular outcome, without the use of a control group. See Virginia Code 38.2-3556
• Certification: means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness. See Virginia Code 38.2-3556
• Civil forfeiture: The loss of ownership of property used to conduct illegal activity.
• Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
• Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. See Virginia Code 38.2-3556
• Commission: means the State Corporation Commission. See Virginia Code 38.2-100
• Company: means any association, aggregate of individuals, business, corporation, individual, joint-stock company, Lloyds type of organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Virginia Code 38.2-100
• Concurrent review: means utilization review conducted during a patient's hospital stay or course of treatment. See Virginia Code 38.2-3556
• Constitutional officer: means an officer provided for pursuant to Article VII, § 4 of the Constitution. See Virginia Code 15.2-102
• Council: means the governing body of a city or town. See Virginia Code 15.2-102
• County: means any existing county or such unit hereafter created. See Virginia Code 15.2-102
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Virginia Code 38.2-3556
• creditor: means the holder, payee, or obligee of a judgment lien and includes the lien creditor as noted on the recorded judgment or abstract of judgment and his successor in interest, including any assignee noted on a recorded assignment or notice of assignment. See Virginia Code 55.1-3100
• Criminal street gang: means the same as that term is defined in § Virginia Code 18.2-513
• Department: means the Department of Taxation. See Virginia Code 58.1-1
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility. See Virginia Code 38.2-3556
• Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) ^{Source: OCC}
• Emergency medical condition: means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. See Virginia Code 38.2-3556
• Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Virginia Code 38.2-3556
• Enterprise: includes any of the following: sole proprietorship, partnership, corporation, business trust, criminal street gang, or other group of three or more individuals associated for the purpose of criminal activity. See Virginia Code 18.2-513
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• Evidence-based standard: means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients. See Virginia Code 38.2-3556
• Expert opinion: means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. See Virginia Code 38.2-3556
• Facility: means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings. See Virginia Code 38.2-3556
• Fair market value: The price at which an asset would change hands in a transaction between a willing, informed buyer and a willing, informed seller.
• Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review entity, at the completion of the health carrier's internal appeal process. See Virginia Code 38.2-3556
• Finance charge: The total cost of credit a customer must pay on a consumer loan, including interest. The Truth in Lending Act requires disclosure of the finance charge. ^{Source: OCC}
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• Fraud: Intentional deception resulting in injury to another.
• Freedom of Information Act: A federal law that mandates that all the records created and kept by federal agencies in the executive branch of government must be open for public inspection and copying. The only exceptions are those records that fall into one of nine exempted categories listed in the statute. ^{Source: OCC}
• Governing body: means the board of supervisors of a county, council of a city, or council of a town, as the context may require. See Virginia Code 15.2-102
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Virginia Code 38.2-3556
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the laws of the Commonwealth. See Virginia Code 38.2-3556
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Virginia Code 38.2-3556
• Health carrier: means an entity, subject to the insurance laws and regulations of the Commonwealth or subject to the jurisdiction of the Commission, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an accident and sickness insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or any other entity providing a plan of health insurance, health benefits, or health care services except as excluded under § Virginia Code 38.2-3556
• Health services plan: means any arrangement for offering or administering health services or similar or related services by a corporation licensed under Virginia Code 38.2-100
• in writing: include any representation of words, letters, symbols, numbers, or figures, whether (i) printed or inscribed on a tangible medium or (ii) stored in an electronic or other medium and retrievable in a perceivable form and whether an electronic signature authorized by Virginia Code 1-257
• Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Virginia Code 38.2-3556
• insurance policies: shall include contracts of fidelity, indemnity, guaranty and suretyship. See Virginia Code 38.2-100
• Insurer: means an insurance company. See Virginia Code 38.2-100
• Interest rate: The amount paid by a borrower to a lender in exchange for the use of the lender's money for a certain period of time. Interest is paid on loans or on debt instruments, such as notes or bonds, either at regular intervals or as part of a lump sum payment when the issue matures. ^{Source: OCC}
• Joint activity: means a governmental function which is carried out by, performed on behalf of, or contracted for two or more localities within a region and includes present and future activities. See Virginia Code 15.2-1307
• Judgment lien: includes a judgment lien pursuant to § Virginia Code 55.1-3100
• Life insurance: includes policies that also provide (i) endowment benefits; (ii) additional benefits incidental to a loss in the event of death, dismemberment, or loss by accident or accidental means; (iii) additional benefits to safeguard the contract from lapse or to provide a special surrender value, a special benefit or an annuity, in the event of total and permanent disability of the insured; and (iv) optional modes of settlement of proceeds. See Virginia Code 38.2-102
• local government: shall be construed to mean a county, city, or town as the context may require. See Virginia Code 15.2-102
• Locality: means all counties, cities and towns within a regional partnership. See Virginia Code 15.2-1307
• Medical or scientific evidence: means evidence found in (i) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (ii) peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. See Virginia Code 38.2-3556
• Medicare: means the "Health Insurance for the Aged Act" Title XVIII of the Social Security Amendment of 1965, as amended. See Virginia Code 38.2-100
• member of the council: means a member of the governing body of a city or town. See Virginia Code 15.2-102
• Month: means a calendar month and "year" means a calendar year. See Virginia Code 1-223
• Mortgage loan: A loan made by a lender to a borrower for the financing of real property. ^{Source: OCC}
• NAIC: means the National Association of Insurance Commissioners. See Virginia Code 38.2-3556
• Notary: means notary public. See Virginia Code 1-226
• Open-end credit: A credit agreement (typically a credit card) that allows a customer to borrow against a preapproved credit line when purchasing goods and services. The borrower is only billed for the amount that is actually borrowed plus any interest due. (Also called a charge account or revolving credit.) ^{Source: OCC}
• Oversight: Committee review of the activities of a Federal agency or program.
• Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds type of organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Virginia Code 38.2-100
• President pro tempore: A constitutionally recognized officer of the Senate who presides over the chamber in the absence of the Vice President. The President Pro Tempore (or, "president for a time") is elected by the Senate and is, by custom, the Senator of the majority party with the longest record of continuous service.
• Proceeds: means the same as that term is defined in § Virginia Code 18.2-513
• Property: means the piece or pieces of real property that are the subject of the settlement and cited on the notice and release. See Virginia Code 55.1-3100
• Prosecute: To charge someone with a crime. A prosecutor tries a criminal case on behalf of the government.
• Prospective review: means utilization review conducted prior to an admission or a course of treatment. See Virginia Code 38.2-3556
• provider: means a health care professional or a facility. See Virginia Code 38.2-3556
• Racketeering activity: means to commit, attempt to commit, or conspire to commit or to solicit, coerce, or intimidate another person to commit two or more of the following offenses: Article 2. See Virginia Code 18.2-513
• rates: means any rate of premium, policy fee, membership fee or any other charge made by an insurer for or in connection with a contract or policy of insurance. See Virginia Code 38.2-100
• real estate: includes lands, tenements and hereditaments, and all rights and appurtenances thereto and interests therein, other than a chattel interest. See Virginia Code 1-219
• Region: means a planning district; however, by agreement of the localities of the planning district, localities which are not part of a planning district may be added to the region if the locality's governing body by vote agrees to become part of the region. See Virginia Code 15.2-1307
• Regional partnership: means an organization composed of government, business, education and civic leaders approved by the local governing bodies of the region to carry out the provisions of this chapter. See Virginia Code 15.2-1307
• reproduction: shall be deemed to include photographs, microphotographs, microfilm, microcard, printouts, optical imaging or other reproductions of electronically stored data, or any other reproduction of an original from a process which forms a durable medium for its recording, storing, and reproducing. See Virginia Code 58.1-106
• Retrospective review: means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment. See Virginia Code 38.2-3556
• Second opinion: means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service. See Virginia Code 38.2-3556
• Settlement agent: means the same as it is defined in § Virginia Code 55.1-3100
• State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100
• Subpoena: A command to a witness to appear and give testimony.
• Subpoena duces tecum: A command to a witness to produce documents.
• Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201
• Summons: Another word for subpoena used by the criminal justice system.
• Supervisor: means a member of the board of supervisors of a county. See Virginia Code 15.2-102
• Testify: Answer questions in court.
• Town: means any existing town or an incorporated community within one or more counties which became a town before noon, July one, nineteen hundred seventy-one, as provided by law or which has within defined boundaries a population of 1,000 or more and which has become a town as provided by law. See Virginia Code 15.2-102
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Utilization review: means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. See Virginia Code 38.2-3556
• Utilization review entity: means an individual or entity that conducts utilization review. See Virginia Code 38.2-3556
• Venue: The geographical location in which a case is tried.