{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.10.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.10.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.10.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.10.html"}],"law_id":56529,"edition_id":1,"section_id":56529,"structure_id":14765,"section_number":"32.1-137.10","catch_line":"Utilization review plan required","history":"1998, c. 891; 1999, c. 857.","full_text":"A\n\nEach utilization review entity subject to this article shall adopt a utilization review plan that contains procedures for complying with the requirements and standards of \u00a7 32.1-137.9 and other applicable provisions of this article. Such plan shall contain, at a minimum, the following:1\n\nSpecific 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\n\nA 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\n\nA 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\n\nA 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; and5\n\nPolicies and procedures designed to ensure confidentiality of patient-specific medical records and information in accordance with subsection C of § 32.1-137.12.B\n\nEach 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\n\nThe 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.","order_by":null,"text":{"0":{"id":206920,"text":"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 \u00a7 32.1-137.9 and other applicable provisions of this article. Such plan shall contain, at a minimum, the following:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":206921,"text":"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;","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":206922,"text":"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;","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"A3"},"3":{"id":206923,"text":"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;","type":"section","prefixes":["A","3"],"prefix":"3","entire_prefix":"A3","prefix_anchor":"A3","level":2,"prior_prefix":"A2","next_prefix":"A4"},"4":{"id":206924,"text":"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","type":"section","prefixes":["A","4"],"prefix":"4","entire_prefix":"A4","prefix_anchor":"A4","level":2,"prior_prefix":"A3","next_prefix":"A5"},"5":{"id":206925,"text":"Policies and procedures designed to ensure confidentiality of patient-specific medical records and information in accordance with subsection C of § 32.1-137.12.","type":"section","prefixes":["A","5"],"prefix":"5","entire_prefix":"A5","prefix_anchor":"A5","level":2,"prior_prefix":"A4","next_prefix":"B"},"6":{"id":206926,"text":"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.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A5","next_prefix":"C"},"7":{"id":206927,"text":"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.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B"}},"ancestry":[{"id":14765,"edition_id":1,"name":"Utilization Review Standards and Appeals","identifier":"1.2","label":"article","depth":3,"order_by":1,"parent_id":12728,"metadata":{},"date_created":"2026-06-26 03:49:48","date_modified":"2026-06-26 03:49:48","permalink":{"id":203121,"object_type":"structure","relational_id":14765,"identifier":"1.2","token":"32.1\/5\/1.2","url":"\/32.1\/5\/1.2\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12728,"edition_id":1,"name":"Regulation of Medical Care Facilities and Services","identifier":"5","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":202855,"object_type":"structure","relational_id":12728,"identifier":"5","token":"32.1\/5","url":"\/32.1\/5\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":56529,"structure_id":14765,"section_number":"32.1-137.10","catch_line":"Utilization review plan required","url":"\/32.1-137.10\/","token":"32.1\/5\/1.2\/32.1-137.10","metadata":false},{"id":83750,"structure_id":14765,"section_number":"32.1-137.11","catch_line":"Accessibility of utilization review entity","url":"\/32.1-137.11\/","token":"32.1\/5\/1.2\/32.1-137.11","metadata":false},{"id":86108,"structure_id":14765,"section_number":"32.1-137.12","catch_line":"Emergencies; extensions; access to and confidentiality of patient-specific medical records and information","url":"\/32.1-137.12\/","token":"32.1\/5\/1.2\/32.1-137.12","metadata":false},{"id":64658,"structure_id":14765,"section_number":"32.1-137.13","catch_line":"Adverse determination","url":"\/32.1-137.13\/","token":"32.1\/5\/1.2\/32.1-137.13","metadata":false},{"id":68683,"structure_id":14765,"section_number":"32.1-137.14","catch_line":"Reconsideration of adverse determination","url":"\/32.1-137.14\/","token":"32.1\/5\/1.2\/32.1-137.14","metadata":false},{"id":57196,"structure_id":14765,"section_number":"32.1-137.15","catch_line":"Adverse determination; appeal","url":"\/32.1-137.15\/","token":"32.1\/5\/1.2\/32.1-137.15","metadata":false},{"id":74476,"structure_id":14765,"section_number":"32.1-137.16","catch_line":"Records","url":"\/32.1-137.16\/","token":"32.1\/5\/1.2\/32.1-137.16","metadata":false},{"id":57237,"structure_id":14765,"section_number":"32.1-137.17","catch_line":"Limitation on Commissioner's jurisdiction","url":"\/32.1-137.17\/","token":"32.1\/5\/1.2\/32.1-137.17","metadata":false},{"id":72177,"structure_id":14765,"section_number":"32.1-137.7","catch_line":"Definitions","url":"\/32.1-137.7\/","token":"32.1\/5\/1.2\/32.1-137.7","metadata":false},{"id":78307,"structure_id":14765,"section_number":"32.1-137.8","catch_line":"Application to and compliance by utilization review entities","url":"\/32.1-137.8\/","token":"32.1\/5\/1.2\/32.1-137.8","metadata":false},{"id":59792,"structure_id":14765,"section_number":"32.1-137.9","catch_line":"Requirements and standards for utilization review entities","url":"\/32.1-137.9\/","token":"32.1\/5\/1.2\/32.1-137.9","metadata":false}],"next_section":{"id":83750,"structure_id":14765,"section_number":"32.1-137.11","catch_line":"Accessibility of utilization review entity","url":"\/32.1-137.11\/","token":"32.1\/5\/1.2\/32.1-137.11","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.10\/","history_text":"

This law was first created in 1998. The record of its establishment is cataloged in chapter 891<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 1 time. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. That modification is as follows: in 1999, chapter 857<\/a>.<\/p>","references":false,"refers_to":[{"id":68683,"section_number":"32.1-137.14","catch_line":"Reconsideration of adverse determination","order_by":null,"url":"\/32.1-137.14\/"},{"id":57196,"section_number":"32.1-137.15","catch_line":"Adverse determination; appeal","order_by":null,"url":"\/32.1-137.15\/"},{"id":59792,"section_number":"32.1-137.9","catch_line":"Requirements and standards for utilization review entities","order_by":null,"url":"\/32.1-137.9\/"}],"permalink":{"id":203123,"object_type":"law","relational_id":56529,"identifier":"32.1-137.10","token":"32.1\/5\/1.2\/32.1-137.10","url":"\/32.1-137.10\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.10\/","token":"32.1\/5\/1.2\/32.1-137.10","dublin_core":{"Title":"Utilization review plan required","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.10","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each utilization review entity<\/span> subject to this article shall adopt a utilization review plan<\/span> that contains procedures for complying with the requirements and standards of \u00a7 32.1-137.9<\/a> and other applicable provisions of this article. Such plan shall contain, at a minimum, the following: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> 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; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A provision for advance notice to covered persons<\/span> 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; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> A provision for advance notice to covered persons<\/span> that compliance with the review process is not a guarantee of benefits or payment under the health benefit plan; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> A provision for a process for reconsideration of adverse decisions in accordance with § 32.1-137.14<\/a> and an appeals<\/span> process in accordance with § 32.1-137.15<\/a>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Policies and procedures designed to ensure confidentiality of patient-specific medical records and information in accordance with subsection C of § 32.1-137.12<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Each utilization review entity<\/span> subject to this chapter shall make available to providers<\/span> and covered persons<\/span>, upon written request, a copy of those portions of its utilization review plan<\/span> relevant to the specific request. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Commissioner<\/span> shall have the right to determine that an entity has complied with the requirement that the entity adopt a utilization review plan<\/span> in accordance with subsection A. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nUTILIZATION REVIEW PLAN REQUIRED (\u00a7 32.1-137.10)\n\nA. Each utilization review entity subject to this article shall adopt a\nutilization review plan that contains procedures for complying with the\nrequirements and standards of \u00a7 32.1-137.9 and other applicable provisions of\nthis article. Such plan shall contain, at a minimum, the following:\n\n 1. Specific procedures to be used in review determinations, including an\n expedited review of no more than twenty-four hours for review determinations\n relating to prescriptions for the alleviation of cancer pain;\n\n 2. A provision for advance notice to covered persons of any requirements for\n certification of the health care setting or pre-approval of the necessity of\n health care service or any other prerequisites to approval of payment;\n\n 3. A provision for advance notice to covered persons that compliance with the\n review process is not a guarantee of benefits or payment under the health\n benefit plan;\n\n 4. A provision for a process for reconsideration of adverse decisions in\n accordance with § 32.1-137.14 and an appeals process in accordance with\n § 32.1-137.15; and\n\n 5. Policies and procedures designed to ensure confidentiality of\n patient-specific medical records and information in accordance with subsection\n C of § 32.1-137.12.\n\nB. Each utilization review entity subject to this chapter shall make available\nto providers and covered persons, upon written request, a copy of those portions\nof its utilization review plan relevant to the specific request.\n\nC. The Commissioner shall have the right to determine that an entity has\ncomplied with the requirement that the entity adopt a utilization review plan in\naccordance with subsection A.\n\nHISTORY: 1998, c. 891; 1999, c. 857.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}