Administrative Code

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

12VAC5-405-40. Definitions.

For the purposes of this chapter:

"Adverse decision" means a utilization review determination by the private review agent that a health service rendered or proposed to be rendered was or is not medically necessary when such determination may result in noncoverage of the health service or health services. If the provider and private review agent reach agreement prior to the issuance of an adverse decision, then no adverse decision has occurred.

"Attending physician" means the physician with primary responsibility for the care subject to review.

"Business days" means all days other than weekends and legal holidays.

"Certificate" means a certificate of registration granted by the Virginia Department of Health to a private review agent.

"Department" means the Virginia Department of Health.

"Initial adverse recommendation" means a reviewer's recommendation, made prior to providing the attending physician a reasonable opportunity to consult with a physician advisor, that an adverse decision be issued.

"Insurer" means an insurance company, health services plan, health maintenance organization, preferred provider organization or multiple employer welfare arrangement.

"Operating in this Commonwealth" means providing utilization review services affecting insureds, subscribers, members or enrollees with respect to an insurance or subscription contract issued for delivery or delivered in Virginia.

"Peer" means a person who has an equivalent degree of education, skill, and licensure as another.

"Physician advisor" means a physician licensed to practice medicine who provides medical advice or information to a private review agent or a utilization review entity in connection with its utilization review activities.

"Private review agent" means a person or entity performing utilization reviews, except that the term shall not include the following entities or employees of any such entity so long as they conduct utilization reviews solely for subscribers, policyholders, members or enrollees:

1. A health maintenance organization authorized to transact business in Virginia; or

2. A health insurer, hospital service corporation, health services plan or preferred provider organization authorized to offer health benefits in this Commonwealth.

"Provider" means an individual or organization that provides personal health services.

"Staff" means persons employed or under contract to perform utilization review on behalf of a private review agent.

"Utilization review" means a system for reviewing the necessity, appropriateness and efficiency of hospital, medical or other health care resources rendered or proposed to be rendered to a patient or group of patients for the purpose of determining whether such services should be covered or provided by an insurer, health services plan, health maintenance organization or other entity or person. For the purposes of this chapter, "utilization review" shall include, but not be limited to, preadmission, concurrent and retrospective medical necessity determination, and review related to the appropriateness of the site at which services were or are to be delivered. "Utilization review" shall not include (i) any review of issues concerning insurance contract coverage or contractual restrictions on facilities to be used for the provision of services, (ii) any review of patient information by an employee of or consultant to any licensed hospital for patients of such hospital, or (iii) any determination by an insurer as to the reasonableness and necessity of services for the treatment and care of an injury suffered by an insured for which reimbursement is claimed under a contract of insurance covering any classes of insurance defined in §§ 38.2-117 through 38.2-119, 38.2-124 through 38.2-126, 38.2-130 through 38.2-132 and 38.2-134.

"Utilization review program" means a program for conducting utilization reviews by a private review agent.

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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