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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 405. Rules Governing Private Review Agents
12/30/2024

12VAC5-405-50. Certificates to perform utilization review.

A. Beginning July 1, 1998, a private review agent not operating in this Commonwealth shall obtain a certificate from the department prior to operating in this Commonwealth.

B. Private review agents operating in this Commonwealth prior to July 1, 1998, shall submit an application for a certificate on or before July 1, 1998.

C. An applicant for a certificate shall pay an application fee and shall submit an application to the department on the forms or in the manner prescribed by the department. The applicant shall also submit the following information required by § 32.1-138.9 of the Code of Virginia:

1. A description of the procedures to be used in evaluating proposed or delivered hospital, medical or other health care services;

2. The procedures by which patients or providers may seek reconsideration of determinations by private review agents;

3. The type and qualifications of the staff either employed or under contract to perform the utilization review;

4. Procedures and policies which ensure that patient-specific medical records and information shall be kept strictly confidential except as authorized by the patient or by 12VAC5-405-100; and

5. Assurances that reviewers will be readily accessible by telephone to patients and providers at least 40 hours per week during normal business hours.

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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