Administrative Code

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

12VAC5-405-90. Appeals of adverse decisions.

A. Private review agents shall include in their procedures, an appeal process that can be utilized when an adverse decision is made. In addition to any notice provided to the patient by a private review agent, providers also may notify the patient of any adverse decision and providers may file an appeal on behalf of the patient. A private review agent and/or insurer may set a reasonable period of time after notification of an adverse decision within which an appeal must be filed.

B. Any case under appeal shall be reviewed by a physician advisor or peer of the provider who proposes the care under review or who was primarily responsible for the care under review. Chiropractic appeals shall be reviewed by a chiropractor. With the exception of expedited appeals, physician advisors who review cases under appeal must be board certified or board eligible and must be specialized in a discipline pertinent to the issue under review. Those who review cases under appeal must not have participated in the adverse decision being appealed.

C. When an adverse decision is made during ongoing treatment and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination by telephone on an expedited basis. Private review agents shall provide for reasonable access by providers to their physician advisor(s) for such appeals. Both providers and private review agents shall attempt to share the maximum information by telephone, facsimile machine, or otherwise to satisfactorily resolve the expedited appeal. Expedited appeals which cannot resolve a difference of opinion may be reconsidered in the standard appeals process unless the physician advisor reviewing the case under expedited appeal meets the requirements set out in subsection B of this section for standard appeals, and all material information and documentation was reasonably available to the provider and to the private review agent at the time of the expedited appeal. The private review agent shall make decisions on expedited appeals within four business days of receiving all pertinent information.

D. The private review agent shall provide an opportunity during the appeal process for the provider to provide additional information and documentation. For appeals not subject to subsection C of this section, appeals will be made in writing or telephonically by the process established by the private review agent. Private review agents shall transmit their determination on the appeal as soon as practicable, but in no case more than 60 days after receiving the required documentation on an appeal. The required documentation may include, among other things, copies of part or all of the medical record and/or a written statement from the provider. The private review agent shall provide that such documentation be reviewed by a physician advisor or peer of the provider individual who proposes the care under review or who was primarily responsible for the care under review. In the case of chiropractic appeals, such documentation shall be reviewed by a chiropractor. A provider who has been unsuccessful in overturning an adverse decision has the right to request of the private review agent the medical basis for that determination. The private review agent shall furnish the support for that determination within 30 business days.

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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