Administrative Code

Virginia Administrative Code
Title 16. Labor and Employment
Agency 30. Virginia Workers' Compensation Commission
1/26/2020

Chapter 70. Plan of Operation for the Medical Costs Peer Review Statewide Coordinating Committee under the Virginia Workers' Compensation Act

Part I
General Information

16VAC30-70-10. Authority for plan of operation.

Chapter 13 (§ 65.2-1300 et seq.) of Title 65.2 of the Code of Virginia vests authority in the Statewide Coordinating Committee for the administration of a peer review program.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 1.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-20. Definitions.

As used in this plan of operation, the words and terms shall have the meanings as set forth herein and in § 65.2-1300 of the Code of Virginia unless the context clearly requires a different meaning.

"Commission" means the Virginia Workers' Compensation Commission.

"Committee" means the Statewide Coordinating Committee.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 1.2, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-30. Purpose of plan of operation.

These provisions establish the internal operating procedures for the committee and its staff. The plan of operation is descriptive in order to facilitate the performance of the committee's administrative functions, but the procedures shall not be exclusive.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 1.3, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-40. [Reserved]

Part II
Meetings of the Committee

16VAC30-70-50. Scheduled meetings.

A. Regular meetings shall be scheduled twice a year, on the call of the chairman of the committee. Special meetings may be called by the chairman or on the request of three or more members of the committee. Notice of committee meetings shall be mailed in advance by the secretary. The committee may, in lieu of a meeting, act pursuant to a telephone conference call to all members or by written ballot sent to all members provided that any such action shall be approved by a majority of the members then serving.

B. Committee meetings shall be conducted as follows:

1. A quorum shall consist of five members;

2. The chairman or his designated substitute shall preside;

3. The vote of the majority of the members present shall be adopted;

4. The secretary shall take minutes.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 2.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-60. Compensation.

Each member of the committee is entitled, pursuant to § 65.2-1302 of the Code of Virginia, to receive such compensation as may be specified by the commission, together with all necessary expenses incurred. The member shall file the appropriate forms and receipts with the secretary for reimbursement.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 2.2, eff. Jan. 9, 1981; July 16, 1993.

Part III
Peer Review System

16VAC30-70-70. Appointment of peer review committees.

A. The committee shall establish a regional peer review committee in each health systems area of the Commonwealth.

B. Each regional peer review committee shall be composed of five physicians who practice in the health systems area and treat recipients of workers' compensation benefits. The physician member of the committee who represents that health systems area shall be one of the members of, and shall serve as chairman of, the regional peer review committee.

C. The Medical Society of Virginia may nominate to the committee physicians having these qualifications. The committee may request additional nominees.

D. The term of the chairman shall be concurrent with his term on the committee. Appointments of members other than the chairman shall be made for terms of three years or the unexpired portions thereof. A vacancy other than by expiration of term shall be filled by the chairman of the committee for the unexpired term.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 3.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-80. Rules and regulations.

The committee, subject to the approval of the Virginia Workers' Compensation Commission, shall adopt and amend such rules and regulations as may be necessary to implement the peer review program.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 3.2, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-70-90. Administration.

The committee shall assist the regional peer review committees in administrative and procedural matters and shall monitor the performance of these committees to ensure consistent implementation of the peer review program throughout the Commonwealth. The committee shall not participate in substantive decisions by regional peer review committees.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 3.3, eff. Jan. 9, 1981; July 16, 1993.

Part IV
Staff

16VAC30-70-100. Staff.

A. The committee may employ a secretary, subject to the approval of the commission, to perform various administrative functions of the committee, including the following:

1. All requests for peer review shall be submitted to the secretary who shall review each request for completeness. Completed requests shall be forwarded by the secretary to the chairman of the appropriate regional committee or to a member designated by the chairman.

2. The secretary shall send notice of peer review to the defending party promptly by certified mail, return receipt requested. A copy shall be sent to the party requesting review.

3. The secretary shall schedule an informal hearing on a request for peer review on the next open agenda, but in no case later than 180 days after receipt of request. Notice of the informal hearing date shall be sent by certified mail, return receipt requested, to the defending party and to the party requesting review no later than 15 days prior to the hearing.

4. The secretary shall prepare an agenda for meetings of the Statewide Coordinating Committee at the direction of its chairman. Notice of the meeting and the proposed agenda shall be mailed by the secretary to committee members in advance.

5. The secretary shall assist in the preparation of committee reports.

B. The committee may hire additional staff or contract for services as may be required from time to time subject to the approval of the Virginia Workers' Compensation Commission.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 4.1, eff. Jan. 9, 1981; July 16, 1993.

Part V
Forms and Reports

16VAC30-70-110. Forms.

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.

16VAC30-70-120. Reports.

The committee shall prepare and distribute the following reports:

1. A statistical report that shall accumulate regional totals and state totals annually for the following:

a. Number of requests for peer review;

b. Number of informal hearings;

c. Number of decisions favorable to physician;

d. Number of decisions favorable to employer/insurer;

e. Number of appeals to the Virginia Workers' Compensation Commission;

f. Number of appeals to state courts.

2. Special reports that shall be prepared from time to time to:

a. Publicize the availability of the peer review program to physicians, the insurance industry, and employers;

b. Advise persons interested in the program of the mechanics of the program.

Statutory Authority

§ 65.2-1309 of the Code of Virginia.

Historical Notes

Derived from VR405-02-02 § 5.2, eff. Jan. 9, 1981; July 16, 1993.



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