Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Section 12VAC5-405-90 - Appeals of adverse decisions

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Private review agents shall include in their procedures, an appeal process that
				can be utilized when an adverse decision is made. In addition to any notice
				provided to the patient by a private review agent, providers also may notify
				the patient of any adverse decision and providers may file an appeal on behalf
				of the patient. A private review agent and/or insurer may set a reasonable
				period of time after notification of an adverse decision within which an appeal
				must be filed.
B. Any case under
				appeal shall be reviewed by a physician advisor or peer of the provider who
				proposes the care under review or who was primarily responsible for the care
				under review. Chiropractic appeals shall be reviewed by a chiropractor. With
				the exception of expedited appeals, physician advisors who review cases under
				appeal must be board certified or board eligible and must be specialized in a
				discipline pertinent to the issue under review. Those who review cases under
				appeal must not have participated in the adverse decision being
				appealed.
C. When an adverse
				decision is made during ongoing treatment and the attending physician believes
				that the determination warrants immediate appeal, the attending physician shall
				have an opportunity to appeal that determination by telephone on an expedited
				basis. Private review agents shall provide for reasonable access by providers
				to their physician advisor(s) for such appeals. Both providers and private
				review agents shall attempt to share the maximum information by telephone,
				facsimile machine, or otherwise to satisfactorily resolve the expedited appeal.
				Expedited appeals which cannot resolve a difference of opinion may be
				reconsidered in the standard appeals process unless the physician advisor
				reviewing the case under expedited appeal meets the requirements set out in
				subsection B of this section for standard appeals, and all material information
				and documentation was reasonably available to the provider and to the private
				review agent at the time of the expedited appeal. The private review agent
				shall make decisions on expedited appeals within four business days of
				receiving all pertinent information.
D. The private review agent shall provide an
				opportunity during the appeal process for the provider to provide additional
				information and documentation. For appeals not subject to subsection C of this
				section, appeals will be made in writing or telephonically by the process
				established by the private review agent. Private review agents shall transmit
				their determination on the appeal as soon as practicable, but in no case more
				than 60 days after receiving the required documentation on an appeal. The
				required documentation may include, among other things, copies of part or all
				of the medical record and/or a written statement from the provider. The private
				review agent shall provide that such documentation be reviewed by a physician
				advisor or peer of the provider individual who proposes the care under review
				or who was primarily responsible for the care under review. In the case of
				chiropractic appeals, such documentation shall be reviewed by a chiropractor. A
				provider who has been unsuccessful in overturning an adverse decision has the
				right to request of the private review agent the medical basis for that
				determination. The private review agent shall furnish the support for that
				determination within 30 business days.
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of
					 Virginia.