Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part VII - Utilization Review and Management › Section 12VAC5-408-360 - Utilization review and management

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP licensee shall have a
				  utilization review and management process that complies with the requirements
				  of §§ 32.1-137.7 through 32.1-137.16 of the Code of Virginia and this
				  chapter. The process shall be managed by a licensed physician.
B. In developing its utilization review
				  program, the MCHIP licensee shall utilize the applicable utilization review and
				  management standards of the American Accreditation HealthCare Commission/URAC
				  or the National Committee for Quality Assurance or other nationally recognized
				  accrediting body acceptable to the department, as the criteria for determining
				  compliance with the utilization management and review requirements of this
				  section except in those instances in which state requirements in law or
				  regulation are more stringent. Applicable utilization review and management
				  standards are those included in an accreditation or certification program for a
				  specific type of MCHIP, such as health maintenance organizations or preferred
				  provider organizations, or for utilization review entities such as private
				  review agents licensed in Virginia, to which MCHIPs may delegate utilization
				  review and management services.
C.
				  The MCHIP licensee, or its contracted private review agent or other delegated
				  service entity for utilization review and management services, may demonstrate
				  compliance with the utilization management and review requirements of this
				  section by attaining accreditation or certification with the American
				  Accreditation HealthCare Commission/URAC, the National Committee for Quality
				  Assurance, or other nationally recognized accrediting body with comparable
				  standards for utilization review accepted by the department. The department may
				  require the MCHIP to demonstrate compliance with particular requirements of
				  §§ 32.1-137.7 through 32.1-137.16 of the Code of Virginia, as well as
				  any other pertinent sections, and this chapter that are more stringent than the
				  applicable accreditation requirements. The department may provide a checklist
				  or other standardized method by which MCHIP licensees may demonstrate
				  compliance with the more stringent requirements.
D. An MCHIP licensee that is not accredited
				  by a nationally recognized accrediting body and accepted by the department
				  shall be subject to the triennial comprehensive onsite examination requirements
				  of 12VAC5-408-90 for purposes of
				  demonstrating compliance with the utilization review and management
				  requirements of this section.
E.
				  The purpose of the utilization review process shall be to monitor access to and
				  utilization of health care services with the process ensuring that the conduct
				  of utilization review is:
1. Impartial,
				  timely, consistent and based upon supportive medical evidence;
2. Performed by appropriately qualified
				  health personnel;
3. Comprehensive
				  in assuring that good faith efforts to obtain all information necessary to make
				  utilization review decisions are made;
4. Evaluated routinely so that program
				  changes that determine the necessity, appropriateness, efficiency and efficacy
				  of health care services provided by the MCHIP licensee can be made as a result
				  of the evaluation; and
5. Reported
				  annually to the MCHIP licensee's governing body.