Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Section 12VAC5-405-40 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
For the purposes of this chapter:
"Adverse decision" means a utilization review determination
				  by the private review agent that a health service rendered or proposed to be
				  rendered was or is not medically necessary when such determination may result
				  in noncoverage of the health service or health services. If the provider and
				  private review agent reach agreement prior to the issuance of an adverse
				  decision, then no adverse decision has occurred.
"Attending physician" means the physician with primary
				  responsibility for the care subject to review.
"Business days" means all days other than weekends and legal
				  holidays.
"Certificate" means a certificate of registration granted by
				  the Virginia Department of Health to a private review agent.
"Department" means the Virginia Department of Health.
"Initial adverse recommendation" means a reviewer's
				  recommendation, made prior to providing the attending physician a reasonable
				  opportunity to consult with a physician advisor, that an adverse decision be
				  issued.
"Insurer" means an insurance company, health services plan,
				  health maintenance organization, preferred provider organization or multiple
				  employer welfare arrangement.
"Operating in this Commonwealth" means providing utilization
				  review services affecting insureds, subscribers, members or enrollees with
				  respect to an insurance or subscription contract issued for delivery or
				  delivered in Virginia.
"Peer" means a person who has an equivalent degree of
				  education, skill, and licensure as another.
"Physician advisor" means a physician licensed to practice
				  medicine who provides medical advice or information to a private review agent
				  or a utilization review entity in connection with its utilization review
				  activities.
"Private review agent" means a person or entity performing
				  utilization reviews, except that the term shall not include the following
				  entities or employees of any such entity so long as they conduct utilization
				  reviews solely for subscribers, policyholders, members or enrollees:
1. A health maintenance organization
				authorized to transact business in Virginia; or
2. A health insurer, hospital service
				corporation, health services plan or preferred provider organization authorized
				to offer health benefits in this Commonwealth.
"Provider" means an individual or organization that provides
				  personal health services.
"Staff" means persons employed or under contract to perform
				  utilization review on behalf of a private review agent.
"Utilization review" means a system for reviewing the
				  necessity, appropriateness and efficiency of hospital, medical or other health
				  care resources rendered or proposed to be rendered to a patient or group of
				  patients for the purpose of determining whether such services should be covered
				  or provided by an insurer, health services plan, health maintenance
				  organization or other entity or person. For the purposes of this chapter,
				  "utilization review" shall include, but not be limited to, preadmission,
				  concurrent and retrospective medical necessity determination, and review
				  related to the appropriateness of the site at which services were or are to be
				  delivered. "Utilization review" shall not include (i) any review of issues
				  concerning insurance contract coverage or contractual restrictions on
				  facilities to be used for the provision of services, (ii) any review of patient
				  information by an employee of or consultant to any licensed hospital for
				  patients of such hospital, or (iii) any determination by an insurer as to the
				  reasonableness and necessity of services for the treatment and care of an
				  injury suffered by an insured for which reimbursement is claimed under a
				  contract of insurance covering any classes of insurance defined in §§
				  38.2-117 through 38.2-119, 38.2-124 through 38.2-126, 38.2-130 through 38.2-132
				  and 38.2-134.
"Utilization review program" means a program for conducting
				  utilization reviews by a private review agent.
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of
					 Virginia.