LIS

Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 405. Rules Governing Private Review Agents
11/21/2024

12VAC5-405-30. Scope.

This chapter applies to all private review agents performing utilization review in this Commonwealth. This chapter does not apply to insurers, health services plans, hospital service corporations, preferred provider organizations, or health maintenance organizations conducting utilization reviews solely for their own insureds, subscribers, members, or enrollees. This chapter does not apply to a private review agent in its conduct of utilization review for self-insured groups or a private review agent in its fulfillment of a contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act (Public Law 89-97, 79 Stat 286 (July 30, 1965)) or in its fulfillment of a contract with a plan otherwise exempt from operation of Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia pursuant to the Employee Retirement Income Security Act of 1974 (29 USC § 1001 et seq.). This chapter does not apply to utilization review conducted in workers' compensation claims or bodily injury liability claims, including uninsured motorist claims. This chapter does not apply to utilization reviews conducted by a provider peer review organization solely for the use of such organization or its members.

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.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.