Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 405. Rules Governing Private Review Agents

12VAC5-405-120. Examination of private review agents.

A. The department may conduct reviews of the operations of private review agents operating in this Commonwealth to determine if the private review agent is operating in compliance with this chapter and Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia. The reviews may include telephone audits to determine if the private review agents are accessible as required by this chapter.

B. The department may investigate any complaint from a health care provider or patient regarding the compliance of a private review agent with the requirements of this chapter or Article 2.1 of Chapter 5 of Title 32.1 of the Code of Virginia.

C. The investigation of private review agents shall not include individual determinations of medical necessity or appropriate charges for covered services. If there is evidence which indicates an alleged pattern of misconduct with respect to utilization review performed by a private review agent, the department may take such action it deems appropriate to correct such pattern of misconduct.

Statutory Authority

§§ 32.1-138.7 and 32.1-138.15 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 15, Issue 20, eff. July 21, 1999.

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