{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.13.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.13.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.13.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.13.html"}],"law_id":64658,"edition_id":1,"section_id":64658,"structure_id":14765,"section_number":"32.1-137.13","catch_line":"Adverse determination","history":"1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.","full_text":"A\n\nThe 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\n\nNo 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.","order_by":null,"text":{"0":{"id":235328,"text":"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.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":235329,"text":"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.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A"}},"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}],"previous_section":{"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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.13\/","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 4 times. 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. Those modifications are as follows: in 1999, chapter 857<\/a>; in 2001, chapter 22<\/a>; in 2010, chapter 395<\/a>; in 2011, chapter 788<\/a>.<\/p>","references":[{"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\/"}],"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\/"}],"permalink":{"id":203135,"object_type":"law","relational_id":64658,"identifier":"32.1-137.13","token":"32.1\/5\/1.2\/32.1-137.13","url":"\/32.1-137.13\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.13\/","token":"32.1\/5\/1.2\/32.1-137.13","dublin_core":{"Title":"Adverse determination","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.13","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> The treating provider<\/span> shall be notified in writing of any adverse determination<\/span> within two working days of the determination; however, the treating provider<\/span> shall be notified orally by telephone within 24 hours of any adverse determination<\/span> for a prescription known to be for the alleviation of cancer pain. Any such notification shall include instructions for the provider<\/span> on behalf of the covered person<\/span> to (i) seek a reconsideration of the adverse determination<\/span> pursuant to § 32.1-137.14<\/a>, including the contact name, address, and telephone number of the person responsible for making the adverse determination<\/span>, and (ii) seek an appeal<\/span> of the adverse determination<\/span> pursuant to § 32.1-137.15<\/a>, including the contact name, address, and telephone number to file and perfect such appeal<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> No entity<\/span> shall render an adverse determination<\/span> unless it has made a good faith attempt to obtain information from the provider. At any time before the entity<\/span> renders its determination, the provider shall be entitled to review the issue<\/span> of medical necessity with a physician advisor<\/span> or peer of the treating health care provider<\/span><\/span> who represents the entity<\/span>. For any adverse determination<\/span> relating to a prescription to alleviate cancer pain, a physician advisor<\/span> shall review the issue<\/span> of medical necessity with the provider. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nADVERSE DETERMINATION (\u00a7 32.1-137.13)\n\nA. The treating provider shall be notified in writing of any adverse\ndetermination within two working days of the determination; however, the\ntreating provider shall be notified orally by telephone within 24 hours of any\nadverse determination for a prescription known to be for the alleviation of\ncancer pain. Any such notification shall include instructions for the provider\non behalf of the covered person to (i) seek a reconsideration of the adverse\ndetermination pursuant to § 32.1-137.14, including the contact name,\naddress, and telephone number of the person responsible for making the adverse\ndetermination, and (ii) seek an appeal of the adverse determination pursuant to\n§ 32.1-137.15, including the contact name, address, and telephone number to\nfile and perfect such appeal.\n\nB. No entity shall render an adverse determination unless it has made a good\nfaith attempt to obtain information from the provider. At any time before the\nentity renders its determination, the provider shall be entitled to review the\nissue of medical necessity with a physician advisor or peer of the treating\nhealth care provider who represents the entity. For any adverse determination\nrelating to a prescription to alleviate cancer pain, a physician advisor shall\nreview the issue of medical necessity with the provider.\n\nHISTORY: 1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.","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}}