Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 405. Rules Governing Private Review Agents
10/19/2020

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 Volume 15, Issue 20, eff. July 21, 1999.

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