Administrative Code

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Virginia Administrative Code
Title 16. Labor and Employment
Agency 30. Virginia Workers' Compensation Commission
Chapter 70. Plan of Operation for the Medical Costs Peer Review Statewide Coordinating Committee under the Virginia Workers' Compensation Act
9/21/2020

16VAC30-70-110. Forms.

Part V
Forms and Reports

The committee shall promulgate forms to facilitate the acquisition of necessary data and information including the following:

1. A Request for Peer Review that shall include:

a. The name and address of the party requesting review;

b. The name and address of the defending party;

c. The name of the patient;

d. A description of the injury;

e. A description of the medical treatment, services, or costs complained of;

f. Where and when the treatment or services took place;

g. A copy of any other relevant information forming the basis for the request for review.

2. A Notice of Peer Review that shall include:

a. A copy of the request for review;

b. Notice of right of physician, employer, insurer, or counsel, to respond in writing and to appear before the peer review committee at an informal hearing;

c. Notice of requirement that a decision be reached by the peer review committee within 30 days of the informal hearing.

3. A Notice of Informal Hearing that shall include:

a. The date and location of the hearing;

b. Right of physician, employer, insurer, or counsel, to appear before the peer review committee for a period of time not exceeding 20 minutes.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 5.1, eff. Jan. 9, 1981; July 16, 1993.

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