Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 405. Rules Governing Private Review Agents
7/8/2020

12VAC5-405-80. Adverse Decisions.

A. With the exception of adverse decisions made on the basis of retrospective review, prior to the issuance of an adverse decision, and if requested by the provider, the case in question must be reviewed either by a physician advisor or by a peer of the provider proposing the care. In addition, to the extent appropriate, the case in question must be reviewed in consultation with a physician advisor with experience in the same field of practice as the attending physician. The physician advisor or peer must be on the staff of the private review agent.

B. With the exception of retrospective reviews, the private review agent must make a reasonable attempt to communicate an initial adverse recommendation to the attending physician prior to the issuance of an adverse decision. With the exception of retrospective reviews, the private review agent must provide the attending physician a reasonable opportunity to consult with a physician advisor prior to the issuance of an adverse decision. Attending physicians and private review agents shall attempt to share the maximum information by telephone, facsimile machine, or otherwise prior to the issuance of an adverse decision.

C. Written notification of an adverse decision shall be given to the individual provider and provider organization and shall include the type of review performed, the reason for the adverse decision, the alternate length of treatment or the alternate treatment setting(s), if any, that the private review agent would approve or would have approved, and a description of the appeal process. Written notification of an adverse decision shall be given to the patient and shall include a description of the appeal process. The description of the appeal process shall include relevant information including, but not limited to, time limits, addresses, and telephone and facsimile numbers. The insurer who contracts with the private review agent for utilization review may fulfill the notification requirements for the private review agent.

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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