Part III. Other Procedures
14VAC10-10-160. Insurance.
A. Because the Virginia Birth-Related Neurological Injury Compensation Program (Program) generally is a payer of last resort, each admitted claimant's parent or legal guardian must purchase private health insurance to provide coverage for the actual medically necessary and reasonable expenses as described in § 38.2-5009 A 1 of the Code of Virginia that were, or are, incurred as a result of the admitted claimant's birth-related neurological injury and for the admitted claimant's benefit. The admitted claimant's parent or legal guardian may request the assistance of the Program facilitator in obtaining a suitable health insurance policy for the admitted claimant if he has no preexisting coverage for the admitted claimant upon the admitted claimant's admission into the Program. The Program will reimburse, upon receipt of proof of payment, solely the portion of the premiums that is attributable to the admitted claimant's post-admission coverage and paid for by the admitted claimant's parent or legal guardian. The Program must be provided with a copy of the applicable health insurance policy before benefits are paid by the Program. It is the responsibility of the parents or guardians to seek benefits for which an admitted claimant is eligible by submitting requests to the Program third-party administrator or other appropriate staff person, as indicated on the Program's website. In addition, the parents or guardians of the admitted claimant must identify a primary care physician.
B. Claimants must utilize the primary insurer's in-network providers and facilities unless otherwise authorized by the Program. Utilizing non-network or nonparticipating providers or facilities may result in reduced payment, nonpayment, or nonreimbursement of incurred expenses.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017; amended, Virginia Register Volume 34, Issue 15, eff. March 9, 2018.
14VAC10-10-170. Reimbursement.
Although an admitted claimant has been determined eligible for benefits from the Virginia Birth-Related Injury Compensation Program (Program), parents or caregivers must contact the Program before committing to the purchase of equipment or incurring other expenses for which they may seek reimbursement. Failure to do so may jeopardize reimbursement from the Program. In the case of emergency care rendered or sought during nonbusiness hours, the admitted claimant's family is responsible for contacting the Program the next business day for authorization of services for which the Program is expected to pay.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-180. Claims for reimbursement.
Requests for reimbursement of expenses from medical providers, pharmacies, equipment providers, medically necessary mileage, or other expenses will not be honored if submitted after one year from the date they are incurred. All reimbursement requests must be accompanied by documentation of medical necessity and receipts from providers. This time limit does not apply to expenses incurred prior to acceptance into the Virginia Birth-Related Neurological Injury Compensation Program (Program). All requests for reimbursement for expenses prior to entry into the Program must be submitted within two years of entry into the Program.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-190. Requests for authorization; services outside insurance plan covered area or network.
A. In the event it is medically necessary to take an admitted claimant outside the admitted claimant's applicable insurance plan's covered service area or the primary insurance's provider network for evaluation, surgery, etc., it must be ascertained if the primary insurance plan will pay for benefits and if so, what amount it will pay. After this is determined, the Virginia Birth-Related Neurological Injury Compensation Program (Program) must be contacted for authorization prior to seeking services or the Program may determine not to pay any balance remaining on the bill for these services.
B. If an in-network provider is available for a service and an out-of-network provider is utilized, the Program will reimburse or pay only an amount equal to what the Program would have paid if an in-network provider had been utilized.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-200. Medically necessary travel greater than 100 miles from primary residence.
In the event it is medically necessary to take an admitted claimant outside the local service area (more than 100 miles from the admitted claimant's primary residence) for evaluation, surgery, or other medically necessary care, it must be ascertained prior to the travel if the travel-related expenses will be reimbursed by the Virginia Birth-Related Neurological Injury Compensation Program (Program). If preauthorization is not obtained, the Program may not pay for these travel-related expenses.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-210. Request for benefits not specifically addressed.
This chapter authorizes the Executive Director of the Virginia Birth-Related Neurological Injury Compensation Program (Program) to provide the benefits described without referral to the Board of Directors of the Program except in exceptional circumstances, and in the executive director's discretion. The board, however, realizes that there may be programs, equipment, or other items, which may be of value to an admitted claimant that this chapter does not address. If the parents or guardians feel a benefit not described in this chapter would be of value to the admitted claimant (the executive director is not authorized to provide those benefits without board approval), the parents or guardians should write the board via the executive director, who will bring these requests to the board at its next meeting.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-220. Experimental treatment and therapy.
A. Experimental treatments or therapy not typically covered by health insurance, including conductive education, may be covered up to a maximum of $6,000 per year, combined, with written prior authorization from the Executive Director of the Virginia Birth-Related Neurological Injury Compensation Program (Program). The Board of Directors of the Program recognizes that such therapies or treatments may be useful for some admitted claimants and, therefore, grants this discretionary benefit on a case-by-case basis. Because this benefit is not provided expressly by the Virginia Birth-Related Neurological Injury Compensation Act (§ 38.2-5000 et seq. of the Code of Virginia), however, there is no guarantee of coverage for experimental therapy or treatment. This completely discretionary benefit may be rescinded at any time; especially if such rescission is warranted by the Board of Directors fiduciary obligations set forth in § 38.2-5016 F of the Code of Virginia. Upon such rescission, benefits under this policy will terminate immediately and no admitted claimant will have any further recourse or any basis for a claim for further benefits under this policy.
B. A written request for authorization of experimental treatment or therapy must be submitted to the Program in accordance with the following process:
1. A letter of medical necessity from the admitted claimant's physiatrist, neurologist, or other appropriate treating specialist physician, who also regularly treats other patients with cerebral palsy, must be received by the Program. A letter of medical necessity from a physical therapist is not acceptable.
2. The letter of medical necessity must be received in the Program's offices at least 60 days prior to the desired start of treatment.
3. Evidence as to whether the primary insurers or other payers will cover any portion of the cost must be submitted with the request.
4. At the Program's discretion, all requests for experimental treatments or therapies may be reviewed for medical necessity by an objective qualified physician.
C. All other Program regulations regarding therapies, including the travel policy, are applicable to authorized experimental treatments or therapies. These include:
1. Payment for travel, lodging, and meals on a per diem basis based on current Commonwealth of Virginia rates.
2. For travel other than by car or van, prior authorization must be obtained.
D. Written authorization from the Program must be obtained by the admitted claimant prior to any payments or reimbursements being made by the Program.
E. Total combined costs for experimental treatments or therapies, related equipment, and travel expenses during any single calendar year may not exceed $6,000.
F. Following any experimental therapy treatment, a complete and thorough progress report prepared by the treating facility must be submitted to the Program within 60 days of completion of the therapy.
G. No further sessions or treatments will be authorized prior to the Program's receiving such progress reports. The receipt of the reports does not guarantee that further treatments will be authorized.
H. The Program may request an independent progress evaluation by a qualified physician prior to any reauthorization for subsequent treatments. If the admitted claimant's insurance will not cover this evaluation, the Program will pay for the evaluation at usual and customary rates. If the Program pays for the evaluation, that cost will not be considered to be part of the cost of the treatment.
I. A local qualified provider of the experimental therapy or treatment requested should be utilized unless the Program grants an exception for a specific treatment provider.
J. For any therapy or treatment proposed, no more than 100 hours will be authorized upon initial request. Additional authorization may be provided only after the procedures in subsection F of this section have been followed.
K. Nursing, certified nurse aide, or other personal assistance will not be provided for extended experimental therapy sessions of more than two hours per day unless a letter of medical necessity is received by the Program from an appropriate treating specialist physician. The letter must state specifically that a nurse must be present due to specified health risks to the admitted claimant.
L. In determining whether authorization will be granted for experimental therapy or treatment, the Program will consider, including the following:
1. The overall cost associated with the experimental treatment or therapy. The cost for one person to accompany the admitted claimant, if stated to be medically necessary by the treating physician; the duration of the Program; the expected benefits to the admitted claimant; and the availability of the experimental program in Virginia.
2. The report from the admitted claimant's treating physician regarding the medical necessity for the admitted claimant to participate in the experimental program.
3. Whether there is medically recognized proof of results that the experimental therapy or treatment has benefitted other patients in similar circumstances.
4. The expected frequency and duration of the experimental treatment or therapy requested.
5. The Program may require third party medical reviews to evaluate the potential success, safety, or results of the experimental treatment or therapy.
M. The Program encourages families to seek out clinical trials being conducted by accredited medical facilities, medical schools, or other highly regarded and medically accepted facilities or organizations to help establish the medical efficacy of experimental treatments or therapies.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.
14VAC10-10-230. Disagreements.
A. Disagreements concerning whether a service or item of equipment should be paid for or reimbursed by the Virginia Birth-Related Neurological Injury Compensation Program (Program) may arise. If Program staff and the Program's Executive Director cannot make a determination regarding a request, or cannot resolve a disagreement, then the executive director has been authorized by the Program's Board of Directors to place the admitted claimant's request on the agenda for the board's consideration and determination at its next regular meeting.
B. The parents or guardians, within 30 days of receiving the Program staff's or executive director's written denial of a claim, may submit a written explanation of the dispute, provide documentation supporting the request and demonstrating that procedures for the submission of claims pursuant to this chapter have been followed, and request that the board make a determination regarding the claim at its next regular meeting.
C. The parents or guardians of the admitted claimant may attend a meeting of the board to make a presentation and to provide documentation in support of the request in addition to submitting written materials to the Program.
D. If a dispute is not resolved by the board, a petition of appeal may be filed with the Clerk of the Virginia Workers' Compensation Commission at 1000 DMV Drive, Richmond, Virginia 23220, within 30 days of receipt of written notification of the board's decision.
Statutory Authority
§ 38.2-5002.1 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 33, Issue 23, eff. July 10, 2017.