dcrodriguez/Code-of-Virginia huggingface dataset:
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-134.1. When denial, etc., to duly licensed physician of staff membership or professional privileges improper.
It shall be an improper practice for the governing body of a hospital that has 25 beds or more and that is required by state law to be licensed to refuse or fail to act within 60 days of a completed application for staff membership or professional privileges or deny or withhold from a duly licensed physician staff membership or professional privileges in such hospital, or to exclude or expel a physician from staff membership in such hospital or curtail, terminate or diminish in any way a physician's professional privileges in such hospital, without stating in writing the reason or reasons therefor, a copy of which shall be provided to the physician. If the reason or reasons stated are unrelated to standards of patient care, patient welfare, violation of the rules and regulations of the institution or staff, the objectives or efficient operations of the institution, or the character or competency of the applicant, or misconduct in any hospital, it shall be deemed an improper practice.

Any physician licensed in the Commonwealth to practice medicine who is aggrieved by any violation of this section shall have the right to seek an injunction from the circuit court of the city or county in which the hospital alleged to have violated this section is located prohibiting any such further violation. The provisions of this section shall not be deemed to impair or affect any other right or remedy, provided that a violation of this section shall not constitute a violation of the provisions of this article for the purposes of §§ 32.1-27.3 and 32.1-135.

1979, c. 711; 2025, cc. 166, 180.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-134.2. Clinical privileges for certain practitioners.
The grant or denial of clinical privileges to licensed podiatrists and certified nurse midwives licensed as advanced practice registered nurses pursuant to § 54.1-2957 by any hospital licensed in this Commonwealth, and the determination by the hospital of the scope of such privileges, shall be based upon such practitioner's professional license, experience, competence, ability, and judgment, and the reasonable objectives and regulations of the hospital in which such privileges are sought.

Code 1950, § 32-301.1; 1979, c. 40; 1992, c. 452; 2023, c. 183.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-134.3. Response to applications for clinical privileges.
Whenever a podiatrist or certified nurse midwife licensed as an advanced practice registered nurse makes application to any hospital for clinical privileges, the hospital shall either approve or disapprove the application within 120 calendar days after it has received all necessary information to make a determination as provided in § 32.1-134.2 from the practitioner.

1981, c. 166; 1992, c. 452; 2023, c. 183.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-134.4. Right of podiatrists or advanced practice registered nurses to injunction.
Any licensed podiatrist or certified nurse midwife licensed as an advanced practice registered nurse in Virginia who is aggrieved by any violation of § 32.1-134.2 or 32.1-134.3 shall have the right to seek an injunction from the circuit court of the city or county in which the hospital alleged to have committed the violation is located, prohibiting any further such violation. The provisions of this section shall not be deemed to impair or affect any other right or remedy. A violation of this section, however, shall not constitute a violation of the provisions of this article for the purposes of § 32.1-27.3 or 32.1-135.

1983, c. 259; 1992, c. 452; 2023, c. 183; 2025, cc. 166, 180.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-135. Revocation or suspension of license or certification of hospital or certified nursing facility; restriction or prohibition of new admissions to certified nursing facility.
A. In accordance with applicable regulations of the Board, the Commissioner may (i) restrict or prohibit new admissions to any nursing home or certified nursing facility, (ii) petition the court to impose a civil penalty against any nursing home or certified nursing facility or to appoint a receiver for such nursing home or certified nursing facility, or both, or (iii) revoke the certification or revoke or suspend the license of a hospital or nursing home or the certification of any certified nursing facility for violation of any provision of this article or Article 2 (§ 32.1-138 et seq.) or of any applicable regulation promulgated under this chapter or for permitting, aiding, or abetting the commission of any illegal act in the hospital or nursing home.

All appeals from notice of imposition of administrative sanctions shall be received in writing within 15 days of the date of receipt of such notice. The provisions of the Administrative Process Act (§ 2.2-4000 et seq.) shall be applicable to such appeals.

B. If a license or certification is revoked as herein provided, a new license or certification may be issued by the Commissioner after satisfactory evidence is submitted to him that the conditions upon which revocation was based have been corrected and after proper inspection has been made and compliance with all provisions of this article and applicable state and federal law and regulations hereunder has been obtained.

C. Suspension of a license shall in all cases be for an indefinite time. The Commissioner may completely or partially restore a suspended license or certificate when he determines that the conditions upon which suspension was based have been completely or partially corrected and that the interests of the public will not be jeopardized by resumption of operation. No additional service charges shall be required for restoring such license.

Code 1950, § 32-307; 1979, c. 711; 1989, c. 618; 2025, cc. 166, 180.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-135.1. Certain advertisements prohibited.
No hospital licensed under the provisions of this chapter shall include in any advertisement death rate statistics in such manner as to suggest the relative quality of health or hospital services.

1988, c. 85.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-135.2. Offer or payment of remuneration in exchange for referral prohibited.
No hospital licensed pursuant to this chapter shall knowingly and willfully offer or pay any remuneration directly or indirectly, in cash or in kind, to induce any practitioner of the healing arts or any clinical psychologist to refer an individual or individuals to such hospital. The Board shall adopt regulations as necessary to carry out the provisions of this section. Such regulations shall be developed in conjunction with the State Board of Behavioral Health and Developmental Services and shall be consistent with regulations adopted by such Board pursuant to § 37.2-420. Such regulations shall exclude from the definition of "remuneration" any payments, business arrangements, or payment practices not prohibited by 42 U.S.C. § 1320a, as amended, or any regulations promulgated pursuant thereto.

1990, c. 379; 1996, cc. 937, 980; 2009, cc. 813, 840.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-136. Violation; penalties.
Any person owning, establishing, conducting, maintaining, managing or operating a hospital or nursing home which is not licensed as required by this article shall be guilty of a Class 6 felony.

Code 1950, § 32-310; 1962, c. 551; 1979, c. 711.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137. Certification of medical care facilities under Title XVIII of Social Security Act.
The Board shall constitute the sole agency of the Commonwealth to enter into contracts with the United States government for the certification of medical care facilities under Title XVIII of the United States Social Security Act and any amendments thereto and with the Virginia Department of Medical Assistance Services for the certification of medical care facilities under Title XIX of the United States Social Security Act and any amendments thereto.

1979, c. 711; 1989, c. 618.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.01. Posting of charity care policies.
A. Every hospital shall provide written information about the hospital's charity care policies, including policies related to free and discounted care. Such information shall be posted conspicuously in public areas of the hospital, including admissions or registration areas, emergency departments, and associated waiting rooms. Information regarding specific eligibility criteria and procedures for applying for charity care shall also be (i) provided to a patient at the time of admission or discharge, or at the time services are provided; (ii) included with any billing statements sent to uninsured patients; and (iii) included on any website maintained by the hospital.

B. Every hospital that is subject to the requirements of Title VI of the Civil Rights Act of 1964, as amended, shall make the information required by subsection A available to persons with limited English proficiency in accordance with the most recent U.S. Department of Health and Human Services' Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons.

2009, c. 425; 2022, cc. 678, 679.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.011. Childbirth; postpartum process; doulas.
A. For the purposes of this section:

"Birth" includes both vaginal birth and cesarean section.

"Doula" means a person who provides physical, emotional, and informational support to a pregnant person before, during, and after pregnancy.

"Postpartum process" means the biologic process that happens to both the newborn and birthing person after delivery due to endogenous hormone systems.

B. A health care facility that provides services related to labor and childbirth shall develop policies that:

1. Allow every birthing person to have a companion or doula with the person during birth in addition to a partner or spouse when a partner or spouse is permitted to be present;

2. At the discretion of the treating physician, allow every birthing person to have a companion or doula with the person during birth when a partner or spouse is not permitted to be present;

3. Prioritize newborns bonding with their families in order to facilitate the postpartum process;

4. Will not exclude from care any person giving birth, or interrupt the process of birth without the informed consent of the birthing person, unless at the discretion of the treating physician;

5. Detail the facility's process related to receiving a pregnant person's patient information from any provider regulated under Title 54.1 who has provided care for the pregnant person;

6. Establish processes to transfer and receive pregnant persons across levels of care of licensed facilities within the facility's capacity and capability; and

7. Establish a process to receive individuals who are pregnant, giving birth, or in the postpartum process from locations other than licensed facilities, including a process to receive verbal and written information from individuals with relevant information, including family members, doulas, or a health care provider regulated under Title 54.1.

2025, c. 589.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.02. Hospital discharge procedures.
Before a hospital discharges a patient, it shall, to the extent allowed pursuant to state and federal law, inform and educate the patient, and his family when it is involved in decision making or ongoing care, about his follow-up care, treatment, and services.

2012, cc. 180, 813.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.04. Patient notice of observation or outpatient status.
A. A hospital shall provide oral and written notice to any patient placed under observation or in any other outpatient status, or to such patient's authorized representative, informing the patient of his placement in such status if (i) the patient receives onsite services from the hospital and (ii) such onsite services include a hospital bed and meals that are provided in an area of the hospital other than the emergency department. Such oral and written notice shall be provided not later than 36 hours after placement under observation or in any other outpatient status unless the patient has been discharged or has left the hospital prior to the expiration of such 36-hour period.

B. Such written notice shall be written in clear, understandable language and printed in at least 14-point type. The written notice shall include:

1. A statement that the patient is not admitted to the hospital as an inpatient but is under observation or in such other outpatient status;

2. A statement that such observation or other outpatient status may affect the patient's Medicare, Medicaid, or private health insurance coverage of (i) the current hospital services, including medications and pharmaceutical supplies, and (ii) care at a skilled nursing facility or home or community-based care upon the patient's discharge from the hospital; and

3. A statement that the patient should contact the identified hospital representative or his health insurance plan for more information on his observation or other outpatient status and any available recourse.

C. For any patient placed under observation or in any other outpatient status who is entitled to have payment made under Title XVIII of the Social Security Act (42 U.S.C. § 1395 et seq.), a hospital providing written notice and oral explanation of such notice to the patient which satisfies the provisions of 42 U.S.C. § 1395cc(a)(1)(Y) shall be deemed to have satisfied the provisions of this section.

2015, c. 365; 2018, c. 194.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.05. Information regarding standard charges; advance estimate of patient payment amount for elective procedure, test, or service.
A. Every hospital shall make available to the public on its website a machine-readable file containing a list of all standard charges for all items and services provided by the hospital in accordance with 45 C.F.R. § 180.50, as amended. As used in this subsection, "hospital," "items and services," "machine-readable," and "standard charge" have the same meaning as set forth in 45 C.F.R. § 180.20.

B. Every hospital shall, upon request of a patient scheduled to receive an elective procedure, test, or service to be performed by the hospital, or upon request of such patient's legally authorized representative, made no less than three days in advance of the date on which such elective procedure, test, or service is scheduled to be performed, furnish the patient with an estimate of the payment amount for which the participant will be responsible for such elective procedure, test, or service. Every hospital shall provide written information about the patient's ability to request an estimate of the payment amount pursuant to this section. Such written information shall be posted conspicuously in public areas of the hospital, including admissions or registration areas, and included on any website maintained by the hospital.

2016, c. 448; 2019, cc. 670, 671; 2022, c. 297.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.06. Lyme disease test result information.
A. Every laboratory reporting the results of a test for Lyme disease ordered in an office-based setting by a health care provider shall include a notice to be provided together with such test results when such test results are reported to the health care provider that states: PATIENTS UNDERGOING A LYME DISEASE TEST SHOULD BE AWARE THAT LYME DISEASE TESTS VARY AND MAY PRODUCE RESULTS THAT ARE INACCURATE. THIS MEANS A PATIENT MAY NOT BE ABLE TO RELY ON A POSITIVE OR NEGATIVE RESULT. HEALTH CARE PROVIDERS ARE ENCOURAGED TO DISCUSS LYME DISEASE TEST RESULTS WITH THE PATIENT FOR WHOM THE TEST WAS ORDERED.

B. A laboratory that complies with this section shall be immune from civil liability absent gross negligence or willful misconduct.

2019, c. 435.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.07. Violations of certain provisions; penalty.
If the Commissioner receives a report from the State Corporation Commission that a medical care facility has engaged in a pattern of violations pursuant to § 38.2-3445.01 and the report is substantiated after investigation, the Commissioner may levy a fine upon the medical care facility in an amount not to exceed $1,000 per violation and may take other formal or informal disciplinary action as permitted under this chapter.

2020, cc. 1080, 1081.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.09. Hospital emergency department CPT code data reporting.
A. Every hospital in the Commonwealth that includes an emergency department shall report quarterly to the Department, for the preceding quarter, (i) the total number of visits to the hospital's emergency department, by location, and (ii) the total number of visits to the hospital's emergency department by emergency department evaluation and management (E/M) Physicians' Current Procedural Terminology (CPT) code.

B. The Department shall annually publish a report setting forth the average number of hospital emergency department visits by location and by emergency department E/M CPT code statewide and by region for each month.

C. The Department may enter into a contract or agreement with the nonprofit organization with which the Department has entered into a contract or agreement pursuant to § 32.1-276.4 for the compilation, storage, analysis, and evaluation of data required to be submitted pursuant to this section.

2022, c. 342.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.1. Definitions.
As used in this and the following article, unless the context indicates otherwise:

"Agent" or "insurance agent," when used without qualification, means an individual, partnership, limited liability company, or corporation that solicits, negotiates, procures or effects contracts of insurance or annuity in this Commonwealth.

"Bureau of Insurance" means the State Corporation Commission acting pursuant to Title 38.2.

"Complaint" means any written communication from a covered person primarily expressing a grievance.

"Covered person" means an individual residing in the Commonwealth, whether a policyholder, subscriber, enrollee, or member of a managed care health insurance plan, who is entitled to health care services or benefits provided, arranged for, paid for or reimbursed pursuant to a managed care health insurance plan under Title 38.2.

"Managed care health insurance plan" means an arrangement for the delivery of health care in which a health carrier as defined in § 38.2-5800 undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis which (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services; and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with or employed by the health carrier. Any health maintenance organization as defined in § 38.2-4300 or health carrier that offers preferred provider contracts or policies as defined in § 38.2-3407 or preferred provider subscription contracts as defined in § 38.2-4209 shall be deemed to be offering one or more managed care health insurance plans. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons to use providers who are directly or indirectly managed, owned, under contract with or employed by the health carrier. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider network or set of provider networks.

"Managed care health insurance plan licensee" means a health carrier subject to licensure by the Bureau of Insurance under Title 38.2 who is responsible for a managed care health insurance plan in accordance with Chapter 58 (§ 38.2-5801 et seq.) of Title 38.2.

"Person" means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds type of organization, other organization, partnership, receiver, reciprocal or inter-insurance exchange, trustee or society.

1998, c. 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.10. Utilization review plan required.
A. Each utilization review entity subject to this article shall adopt a utilization review plan that contains procedures for complying with the requirements and standards of § 32.1-137.9 and other applicable provisions of this article. Such plan shall contain, at a minimum, the following:

1. Specific procedures to be used in review determinations, including an expedited review of no more than twenty-four hours for review determinations relating to prescriptions for the alleviation of cancer pain;

2. A provision for advance notice to covered persons of any requirements for certification of the health care setting or pre-approval of the necessity of health care service or any other prerequisites to approval of payment;

3. A provision for advance notice to covered persons that compliance with the review process is not a guarantee of benefits or payment under the health benefit plan;

4. A provision for a process for reconsideration of adverse decisions in accordance with § 32.1-137.14 and an appeals process in accordance with § 32.1-137.15; and

5. Policies and procedures designed to ensure confidentiality of patient-specific medical records and information in accordance with subsection C of § 32.1-137.12.

B. Each utilization review entity subject to this chapter shall make available to providers and covered persons, upon written request, a copy of those portions of its utilization review plan relevant to the specific request.

C. The Commissioner shall have the right to determine that an entity has complied with the requirement that the entity adopt a utilization review plan in accordance with subsection A.

1998, c. 891; 1999, c. 857.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.11. Accessibility of utilization review entity.
A utilization review entity shall provide accessibility for covered persons and providers by free telephone at least forty hours per week during normal business hours. Entities located outside of the eastern time zone shall provide covered persons advance written notification of the eastern time zone hours during which those entities are accessible; however, such hours shall be no less than forty hours per week during normal business hours. The entity shall install and maintain an adequate telephone system that accepts and records messages or accepts and provides recorded business hour information for incoming calls outside of normal business hours.

1998, c. 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.12. Emergencies; extensions; access to and confidentiality of patient-specific medical records and information.
A. For emergency health care, authorization may be requested by the covered person, his representative, or his provider either within forty-eight hours of or by the end of the first business day following the rendering of the emergency health care, whichever is later.

B. An entity shall promptly review a request from the covered person, his representative, or his provider for an extension of the original approved duration of health care or hospitalization. If the entity fails to confirm that termination of health care or hospitalization will occur on the original date authorized, the entity shall review retrospectively whether the extension of health care or hospitalization was medically appropriate.

C. Each entity shall have reasonable access to patient-specific medical records and information.

1998, c. 891.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.13. Adverse determination.
A. The treating provider shall be notified in writing of any adverse determination within two working days of the determination; however, the treating provider shall be notified orally by telephone within 24 hours of any adverse determination for a prescription known to be for the alleviation of cancer pain. Any such notification shall include instructions for the provider on behalf of the covered person to (i) seek a reconsideration of the adverse determination pursuant to § 32.1-137.14, including the contact name, address, and telephone number of the person responsible for making the adverse determination, and (ii) seek an appeal of the adverse determination pursuant to § 32.1-137.15, including the contact name, address, and telephone number to file and perfect such appeal.

B. No entity shall render an adverse determination unless it has made a good faith attempt to obtain information from the provider. At any time before the entity renders its determination, the provider shall be entitled to review the issue of medical necessity with a physician advisor or peer of the treating health care provider who represents the entity. For any adverse determination relating to a prescription to alleviate cancer pain, a physician advisor shall review the issue of medical necessity with the provider.

1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.14. Reconsideration of adverse determination.
A. A treating provider may request reconsideration of an adverse determination pursuant to this section or may appeal an adverse determination pursuant to § 32.1-137.15. Any reconsideration of an adverse determination shall only be requested by the treating provider on behalf of the covered person. A determination on reconsideration shall be made by a physician advisor, peer of the treating health care provider, or a panel of other appropriate health care providers with at least one physician advisor or peer of the treating health care provider on the panel.

B. The treating provider on behalf of the covered person shall be (i) notified verbally at the time of the determination of the reconsideration of the adverse determination and in writing following the determination of the reconsideration of the adverse determination, in accordance with § 32.1-137.9, including the criteria used and the clinical reason for the adverse determination and the alternate length of treatment of the alternate treatment setting or settings, if any, that the entity deems to be appropriate, and (ii) notified verbally at the time of the determination of the reconsideration of the adverse determination of the process for an appeal of the determination pursuant to § 32.1-137.15 and the contact name, address, and telephone number to file and perfect an appeal. If the treating provider on behalf of the covered person requests that the adverse determination be reviewed by a peer of the treating provider at any time during the reconsideration process, the request for reconsideration shall be vacated and considered an appeal pursuant to § 32.1-137.15. In such cases, the covered person shall be notified that the reconsideration has been vacated and an appeal initiated, all documentation and information provided or relied upon during the reconsideration process pursuant to this section shall be converted to the appeal process, and no additional actions shall be required of the treating provider to perfect the appeal.

C. Any reconsideration shall be rendered and the determination provided to the treating provider and the covered person in writing within 10 working days of receipt of the request for reconsideration.

1998, c. 891; 2010, c. 395; 2011, c. 788.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.15. Adverse determination; appeal.
Each entity shall establish an internal appeals process, including a process for urgent care appeals, to consider any adverse determination that is appealed by a covered person, his representative, or his provider in accordance with the provisions of § 38.2-3558.

1998, c. 891; 1999, cc. 643, 649, 857; 2000, c. 922; 2010, c. 395; 2011, c. 788.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.16. Records.
Every entity subject to Article 1.1 (§ 32.1-137.1 et seq.) of Chapter 5 and this article shall maintain or cause to be maintained, in writing and at a location accessible to employees of the Department, records of review procedures; the health care qualifications of the entity's staff; the criteria used by the entity to make its determinations; records of complaints received, including the manner in which the complaints were resolved; the number and type of adverse determinations and reconsiderations; the number and outcome of final adverse determinations and appeals thereof, including a separate record for expedited appeals; and procedures to ensure confidentiality of medical records and personal information. Records of complaints under Article 1.1 (§ 32.1-137.1 et seq.) shall be maintained from the date of the entity's last examination and for no less than six years.

Every entity subject to utilization review under this article shall provide, upon request of the Commissioner, data and records pertaining to utilization review from which patient and provider identifiers have been removed. Records shall be maintained or caused to be maintained by the utilization review entity for a period of six years, and all such records shall be subject to examination by the Commissioner or his designee.

1998, c. 891; 2011, c. 788.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.17. Limitation on Commissioner's jurisdiction.
The Commissioner shall have the right to determine compliance with this article; however, the Commissioner shall have no jurisdiction to adjudicate individual controversies arising out of or incidental to this article.

1998, c. 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.3. Regulations.
Consistent with its duties to protect the health, safety, and welfare of the public, the Board shall promulgate regulations, consistent with this article, governing the quality of care provided to covered persons by a managed care health insurance plan licensee through its managed care health insurance plans on or before December 1, 1999. The regulations may incorporate or apply nationally recognized, generally accepted, quality standards developed by private accreditation entities, if such standards exist and as appropriate for the type of managed care health insurance plan. The regulations shall also include guidelines for the Commissioner to determine, in consultation with the Bureau of Insurance, when the imposition of administrative sanctions as set forth in § 32.1-137.5 or initiation of court proceedings or both are appropriate in order to ensure prompt correction of violations discovered on any examination, review, or investigation conducted by the Department pursuant to provisions of this article.

1998, c. 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.4. Examination, review or investigation.
A. The Commissioner shall cause each managed care health insurance plan licensee subject to certification under this article to be examined or reviewed for each new application and to be periodically examined or reviewed at reasonable times thereafter, including both for complaint investigation and for renewal compliance. Such examinations or reviews shall consider the compliance of the managed care health insurance plan licensee with the regulations promulgated under § 32.1-137.3.

In lieu of or in addition to making his own examination of the managed care health insurance plan licensee, the Commissioner may accept the report of an examination of the licensee under similar laws of another state, similar regulatory agency, state health commissioner, or accreditation entity.

B. Any examiner authorized by the Commissioner shall, so far as necessary for the purposes of the examination or review, have access during regular business hours to the premises and to any books, records, files, or property of the licensee as far as they directly relate to the quality of care provided by the licensee. All material copied or recorded or received shall be privileged and confidential and shall not be subject to subpoena.

C. Every person from whom information is sought, in an investigation of a complaint pursuant to this article against a managed care health insurance plan licensee, shall cooperate in producing or allowing reasonable access during regular business hours to the books, records, files, accounts, papers, documents, and any or all computer or other recordings of the licensee being examined or those of any person delivering health care services under contract, affiliation, delegation or other arrangement directly relevant to the investigation. Such information shall be limited to that which is relevant to the investigation in question, as specified in regulations promulgated pursuant to this article. All material copied or recorded or received shall be privileged and confidential, and shall not be subject to subpoena.

D. The refusal of any licensee, by its officers, directors, employees or agents, to submit to examination or review or to comply with any reasonable written request of the examiners shall be grounds for suspension, revocation, denial, or nonrenewal of any certificate of quality assurance held by the licensee. Any such proceedings for suspension, revocation, denial or nonrenewal of any certificate shall be conducted pursuant to § 32.1-137.5.

1998, c. 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.8. Application to and compliance by utilization review entities.
A. No utilization review entity shall perform utilization review with regard to hospital, medical or other health care resources rendered or proposed to be rendered to a covered person except in accordance with the requirements and standards set forth in this article.

B. This article shall not apply to utilization review performed under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act or under contract with a plan otherwise exempt from operation of this chapter pursuant to the Employee Retirement Income Security Act of 1974.

C. This article shall not apply to private review agents subject to Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia.

D. This article shall not apply to programs administered by the Department of Medical Assistance Services or under contract with the Department of Medical Assistance Services.

1998, cc. 129, 891.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-137.9. Requirements and standards for utilization review entities.
A. Each entity shall establish reasonable and prudent standards and criteria to be applied in utilization review determinations with input from physician advisors representing major areas of specialty and certified by the boards of the various American medical specialties. Such standards shall be objective, clinically valid, and compatible with established principles of health care. Such standards shall further be established so as to be sufficiently flexible to allow deviations from norms when justified on case-by-case bases.

The entity shall make available to any provider or covered person, upon written request, a list of such physician advisors and their major areas of specialty, as well as the standards and criteria established in accordance with this section except as prohibited in accordance with copyright laws.

B. An adverse determination shall be made only in accordance with § 32.1-137.13.

C. Each entity shall have a process for reconsideration of an adverse determination in accordance with § 32.1-137.14 and an appeals process in accordance with § 32.1-137.15.

D. Each entity shall make arrangements to use the services of physician advisors who are specialists in the various categories of health care on "per need" or "as needed" bases in conducting utilization review.

E. Each entity shall have review staff who are properly qualified, trained and supervised, and supported by a physician advisor, to carry out its review determinations.

F. Each entity shall notify its covered persons of the review process, including the appeals process, and shall so notify the covered person's provider upon written request by the provider. An Evidence of Coverage shall contain a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of the process for reconsideration of an adverse determination rendered under § 32.1-137.13, as required by § 32.1-137.14, and the process for internal appeal from an adverse determination under § 32.1-137.15.

G. Each entity shall communicate its utilization review decision no later than two business days after receipt by the entity of all information necessary to complete the review.

H. Each entity shall have a representative, authorized to approve utilization review determinations, available to covered persons and providers in accordance with § 32.1-137.11.

I. The Commissioner shall have the right to determine that an entity has complied with the requirement that the entity establish reasonable and prudent requirements and standards pursuant to this section.

1998, c. 891; 2011, c. 788.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.1. Implementation of transfer and discharge policies.
A. To implement and conform with the provisions of subdivision A 4 of § 32.1-138, a facility may discharge the patient, or transfer the patient, including transfer within the facility, only:

1. If appropriate to meet that patient's documented medical needs;

2. If appropriate to safeguard that patient or one or more other patients from physical or emotional injury;

3. On account of nonpayment for his stay except as prohibited by Titles XVIII or XIX of the United States Social Security Act and the Virginia State Plan for Medical Assistance Services; or

4. With the informed voluntary consent of the patient, or if incapable of providing consent, with the informed voluntary consent of the patient's authorized decision maker pursuant to § 54.1-2986 acting in the best interest of the patient, following reasonable advance written notice.

B. Except in an emergency involving the patient's health or well being, no patient shall be transferred or discharged without prior consultation with the patient, the patient's family or responsible party and the patient's attending physician. If the patient's attending physician is unavailable, the facility's medical director in conjunction with the nursing director, social worker or another health professional, shall be consulted. In the case of an involuntary transfer or discharge, the attending physician of the patient or the medical director of the facility shall make a written notation in the patient's record approving the transfer or discharge after consideration of the effects of the transfer or discharge, appropriate actions to minimize the effects of the transfer or discharge, and the care and kind of service the patient needs upon transfer or discharge.

C. Except in an emergency involving the patient's health or well being, reasonable advance written notice shall be given in the following manner. In the case of a voluntary transfer or discharge, notice shall be reasonable under the circumstances. In the case of an involuntary transfer or discharge, reasonable advance written notice shall be given to the patient at least five days prior to the discharge or transfer.

D. Nothing in this section or in subdivision A 4 of § 32.1-138 shall be construed to authorize or require conditions upon a transfer within a facility that are more restrictive than Titles XVIII or XIX of the United States Social Security Act or by regulations promulgated pursuant to either title.

1987, c. 221; 1993, c. 692.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.10. Expiration; renewal.
Each certificate of registration shall expire on the second anniversary of its effective date unless the certificate of registration is renewed for a two-year term as provided in this section. The Department shall renew the certificate of registration for an additional two-year term if the applicant is otherwise entitled to the certificate of registration, pays to the Department the renewal fee set by regulations, submits to the Department a renewal application on a form prescribed by the Department, submits satisfactory assurances of compliance with the requirements of this article and updates information on file with the Department pursuant to this section.

1990, c. 826, § 38.2-5303; 1998, c. 129.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.11. Denial; revocation.
A. The Department may deny a certificate of registration to any applicant if, upon review of the application, it finds that the applicant proposing to conduct utilization review does not meet the standards required by this article or by any regulations promulgated pursuant to this article.

B. The Department may revoke a certificate of registration, or place the holder on probation with terms and conditions, if the holder demonstrates that it is unable or unwilling to meet the requirements of this chapter or of regulations adopted pursuant to this article.

1990, c. 826, § 38.2-5304; 1998, c. 129.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.12. Waiver of requirements of article.
The Department shall waive the requirements of this article for a private review agent that operates under contract with the federal government for utilization review of patients eligible for hospital services under Title XVIII of the Social Security Act or under contract with a plan otherwise exempt from operation of this chapter pursuant to the Employee Retirement Income Security Act of 1974.

1990, c. 826, § 38.2-5306; 1998, c. 129.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.13. Access to and confidentiality of patient-specific medical records and information.
Private review agents who have been granted a certificate of registration by the Department shall have reasonable access to patient-specific medical records and information to the extent and in the manner authorized by regulation.

1990, c. 826, § 38.2-5307; 1998, c. 129.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.14. No private right of action created.
This article shall not be construed to create a private right of action against a private review agent on behalf of a subscriber, policyholder, member, enrollee or other person.

1990, c. 826, § 38.2-5308; 1998, c. 129.
Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.15. Regulations.
The Department shall promulgate regulations, pursuant to the Administrative Process Act (§ 2.2-4000 et seq.), to implement the provisions of this article, which shall include, but not be limited to, the following items:

1. Minimum qualifications to perform review;

2. Procedures which require the private review agent to provide the attending physician an opportunity to consult with a physician advisor prior to issuance of a final denial in any case in which there is an initial recommendation to deny coverage;

3. Guidelines regarding access to and confidentiality of patient-specific medical records and information; and

4. Setting the amount of any fees required by this article, which shall be sufficient to pay for the administrative costs of regulation under this article.

1990, c. 826, § 38.2-5309; 1998, c. 129.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.2. Certain contract provisions prohibited.
No contract or agreement for nursing home care shall contain any provisions which restrict or limit the ability of a resident to apply for and receive Medicaid or which require a specified period of residency prior to applying for Medicaid. The resident may be required to notify the facility when an application for Medicaid has been made. No contract or agreement may require a deposit or other prepayment from Medicaid recipients. No contract or agreement shall contain provisions authorizing the facility to refuse to accept retroactive Medicaid benefits.

1987, c. 221.

Code of Virginia — Title 32.1 (Health), Chapter 5 (Regulation of Medical Care Facilities and Services)
§ 32.1-138.3. Third party guarantor prohibition.
Any facility certified under Title XVIII or XIX of the United States Social Security Act shall not require a third party guarantee of payment to the facility as a condition of admission or of expedited admission to, or continued stay in, the facility. This section shall not be construed to prevent a facility from requiring an individual who has legal access to a resident's income or resources which are available to pay for care in the facility to sign a contract without incurring personal financial liability except for breach of the duty to provide payment from the resident's income or resources for such care.

For purposes of this section, the resident's income or resources shall include any amount deemed to be income or resources of the resident for purposes of Medicaid eligibility and any resources transferred by the resident to a third party if the transfer disqualifies the resident from Medicaid coverage for nursing facility services.

1989, c. 193.