Administrative Code

Virginia Administrative Code
9/26/2022

Part II. Initial Review

16VAC30-60-80. Requests for peer review.

A. Requests for peer review shall be made on a form prescribed by the Statewide Coordinating Committee and shall set forth or be accompanied by the following:

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

2. The names of any physicians or clinics involved;

3. The name of the patient;

4. A description of the injury;

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

6. A description of where and when the treatment or services took place; and

7. A copy of any other relevant information forming the basis of the request for review, including any evidence indicating that the fees charged are different from those that prevail in the same community for similar treatment when the treatment is paid for by the injured person.

B. Requests for peer review shall be made to the Secretary of the Statewide Coordinating Committee. Requests may be submitted by the commission, a treating physician, any insurance company providing coverage for the cost of services paid for in whole or in part pursuant to the Workers' Compensation Act, or any employer.

C. The Secretary of the Statewide Coordinating Committee shall refer each completed request for review to the chairman of the appropriate regional peer review committee or to a member designated by the chairman.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.1, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-90. Defending party.

A. Any defending party subject to review under 16VAC30-60-80 shall be notified in writing by the Secretary of the Statewide Coordinating Committee.

B. The defending party shall be notified of peer review by certified mail, return receipt requested, within 30 days of the submission of a completed request for review to the Secretary. A copy of the notice shall be sent to the party requesting review.

C. The notice shall include:

1. A copy of the request for review;

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

3. A notice of the requirement that a decision be reached by the peer review committee within 30 days after the informal hearing.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.2, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-100. Assignment for initial review.

A. Each request for review shall be assigned by the chairman of the peer review committee to an individual member for initial investigation and evaluation. The chairman shall establish rotating assignment procedures for equitable distribution among the committee members.

B. A committee member shall disqualify himself from participation in the review and decision of a particular request for review if ethically constrained by a conflict of interest. A committee member shall not participate in any review that relates to any care that he, or one of his associates, has rendered.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.3, eff. Jan. 9, 1981; July 16, 1993.

16VAC30-60-110. Initial evaluation.

A. The committee member shall review the completed request for review, any response submitted by the defending party, and any additional information acquired during investigation.

B. The responsible peer review committee member may request additional information from the physician, the insurer/employer, or any other source that has relevant information. If necessary, the chairman of the peer review committee may request that the commission utilize its powers of investigation.

C. The committee member shall be prepared to make an oral evaluation of the request for review and recommended disposition at the informal hearing. The committee member or chairman has the discretion to resolve the matter in dispute with the consent of the parties and without the necessity of an informal hearing.

Statutory Authority

§ 65.2-1305 of the Code of Virginia.

Historical Notes

Derived from VR405-02-01 § 2.4, eff. Jan. 9, 1981; July 16, 1993.

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