§ 38.2-3556 Definitions
§ 38.2-3557 Scope of chapter
§ 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
§ 38.2-3570 Disclosure requirements
§ 38.2-3571 Regulations

Terms Used In Virginia Code > Title 38.2 > Chapter 35.1 - Health Carrier Internal Appeal Process and External Review

  • 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
  • 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
  • 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
  • Baccalaureate: means that bachelor's degrees or more advanced degrees, or both, are granted. See Virginia Code 23.1-100
  • 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
  • Bequeath: To gift property by will.
  • 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
  • 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
  • Chief executive officer: includes the Chancellor of the Virginia Community College System, the Chancellor of the University of Virginia's College at Wise, the Superintendent of Virginia Military Institute, and the president of each other public institution of higher education. See Virginia Code 23.1-100
  • 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
  • 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
  • Devise: To gift property by will.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 § 38. See 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 Chapter 42 of Title 59. See Virginia Code 38.2-100
  • Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Virginia Code 38.2-3556
  • Indictment: The formal charge issued by a grand jury stating that there is enough evidence that the defendant committed the crime to justify having a trial; it is used primarily for felonies.
  • inhabitants: means with reference to any county, city, town, political subdivision of the Commonwealth or any combination thereof, the natural persons in such county, city, town, political subdivision or combination as shown by the unadjusted United States decennial census last preceding the time at which any provision dependent upon population is being applied or the time as of which it is being construed. See Virginia Code 1-235
  • local government: shall be construed to mean a county, city, or town as the context may require. See Virginia Code 15.2-102
  • 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
  • NAIC: means the National Association of Insurance Commissioners. See Virginia Code 38.2-3556
  • 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.
  • 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
  • Public institution of higher education: includes the System as a whole and each associate-degree-granting and baccalaureate public institution of higher education in the Commonwealth. See Virginia Code 23.1-100
  • Quorum: The number of legislators that must be present to do business.
  • 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
  • State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100
  • Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201
  • System: means the Virginia Community College System. See Virginia Code 23.1-100
  • Testator: A male person who leaves a will at death.
  • 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