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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
6/24/2024

12VAC5-408-360. Utilization review and management.

A. The MCHIP licensee shall have a utilization review and management process that complies with the requirements of §§ 32.1-137.7 through 32.1-137.16 of the Code of Virginia and this chapter. The process shall be managed by a licensed physician.

B. In developing its utilization review program, the MCHIP licensee shall utilize the applicable utilization review and management standards of the American Accreditation HealthCare Commission/URAC or the National Committee for Quality Assurance or other nationally recognized accrediting body acceptable to the department, as the criteria for determining compliance with the utilization management and review requirements of this section except in those instances in which state requirements in law or regulation are more stringent. Applicable utilization review and management standards are those included in an accreditation or certification program for a specific type of MCHIP, such as health maintenance organizations or preferred provider organizations, or for utilization review entities such as private review agents licensed in Virginia, to which MCHIPs may delegate utilization review and management services.

C. The MCHIP licensee, or its contracted private review agent or other delegated service entity for utilization review and management services, may demonstrate compliance with the utilization management and review requirements of this section by attaining accreditation or certification with the American Accreditation HealthCare Commission/URAC, the National Committee for Quality Assurance, or other nationally recognized accrediting body with comparable standards for utilization review accepted by the department. The department may require the MCHIP to demonstrate compliance with particular requirements of §§ 32.1-137.7 through 32.1-137.16 of the Code of Virginia, as well as any other pertinent sections, and this chapter that are more stringent than the applicable accreditation requirements. The department may provide a checklist or other standardized method by which MCHIP licensees may demonstrate compliance with the more stringent requirements.

D. An MCHIP licensee that is not accredited by a nationally recognized accrediting body and accepted by the department shall be subject to the triennial comprehensive onsite examination requirements of 12VAC5-408-90 for purposes of demonstrating compliance with the utilization review and management requirements of this section.

E. The purpose of the utilization review process shall be to monitor access to and utilization of health care services with the process ensuring that the conduct of utilization review is:

1. Impartial, timely, consistent and based upon supportive medical evidence;

2. Performed by appropriately qualified health personnel;

3. Comprehensive in assuring that good faith efforts to obtain all information necessary to make utilization review decisions are made;

4. Evaluated routinely so that program changes that determine the necessity, appropriateness, efficiency and efficacy of health care services provided by the MCHIP licensee can be made as a result of the evaluation; and

5. Reported annually to the MCHIP licensee's governing body.

F. In addition, the utilization review process shall:

1. Allow for flexibility, taking into account individual cases when appropriate;

2. Provide avenues for provider input into the establishment of clinical guidelines and protocols;

3. Afford opportunity for reconsideration and appeal of adverse determinations in a manner that is easily understood and accessed by covered persons and providers; and

4. Be coordinated with other components of the MCHIP that use or could benefit from utilization review data.

G. The utilization review process shall be based upon a written plan that is reviewed annually and that shall contain, at a minimum:

1. A description of the scope of the utilization review process, both internal and external;

2. A description of the organizational responsibilities for utilization review including the qualifications of utilization review personnel;

3. The clinical review guidelines, standards, and protocols which are applied in utilization review determinations;

4. Mechanisms to evaluate uniform application of guidelines and to determine the necessity for case-by-case decision making;

5. Procedures for soliciting and implementing provider input in the development of guidelines as well as evaluating provider usage of the guidelines;

6. A description of the process for monitoring over utilization and under utilization;

7. Provisions for notice to covered persons and providers regarding any need for precertification, concurrent certification, or retrospective review as a prerequisite for approval of payment or access to service;

8. Procedures for reconsideration of adverse decisions and appeals including expedited appeals;

9. Guidelines for the delegation of utilization review to external entities and the expectations for that delegation;

10. Guidelines for the notification in clear and understandable terms of the reasons for denial of services or payments to providers and subscribers;

11. Mechanisms for review and implementation of experimental treatments and new technology;

12. Mechanisms for soliciting and evaluating provider and covered person satisfaction with utilization review determinations and the MCHIP licensee's appeal process and implementing mechanisms to address areas of dissatisfaction; and

13. Procedures for the maintenance of records required under § 32.1-137.16 of the Code of Virginia.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; Errata, 16:7 VA.R. 837 December 20, 1999; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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