{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.14.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.14.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.14.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.14.html"}],"law_id":68683,"edition_id":1,"section_id":68683,"structure_id":14765,"section_number":"32.1-137.14","catch_line":"Reconsideration of adverse determination","history":"1998, c. 891; 2010, c. 395; 2011, c. 788.","full_text":"A\n\nA treating provider may request reconsideration of an adverse determination pursuant to this section or may appeal an adverse determination pursuant to § 32.1-137.15. Any reconsideration of an adverse determination shall only be requested by the treating provider on behalf of the covered person. A determination on reconsideration shall be made by a physician advisor, peer of the treating health care provider, or a panel of other appropriate health care providers with at least one physician advisor or peer of the treating health care provider on the panel.B\n\nThe treating provider on behalf of the covered person shall be (i) notified verbally at the time of the determination of the reconsideration of the adverse determination and in writing following the determination of the reconsideration of the adverse determination, in accordance with § 32.1-137.9, including the criteria used and the clinical reason for the adverse determination and the alternate length of treatment of the alternate treatment setting or settings, if any, that the entity deems to be appropriate, and (ii) notified verbally at the time of the determination of the reconsideration of the adverse determination of the process for an appeal of the determination pursuant to § 32.1-137.15 and the contact name, address, and telephone number to file and perfect an appeal. If the treating provider on behalf of the covered person requests that the adverse determination be reviewed by a peer of the treating provider at any time during the reconsideration process, the request for reconsideration shall be vacated and considered an appeal pursuant to § 32.1-137.15. In such cases, the covered person shall be notified that the reconsideration has been vacated and an appeal initiated, all documentation and information provided or relied upon during the reconsideration process pursuant to this section shall be converted to the appeal process, and no additional actions shall be required of the treating provider to perfect the appeal.C\n\nAny reconsideration shall be rendered and the determination provided to the treating provider and the covered person in writing within 10 working days of receipt of the request for reconsideration.","order_by":null,"text":{"0":{"id":248645,"text":"A treating provider may request reconsideration of an adverse determination pursuant to this section or may appeal an adverse determination pursuant to § 32.1-137.15. Any reconsideration of an adverse determination shall only be requested by the treating provider on behalf of the covered person. A determination on reconsideration shall be made by a physician advisor, peer of the treating health care provider, or a panel of other appropriate health care providers with at least one physician advisor or peer of the treating health care provider on the panel.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":248646,"text":"The treating provider on behalf of the covered person shall be (i) notified verbally at the time of the determination of the reconsideration of the adverse determination and in writing following the determination of the reconsideration of the adverse determination, in accordance with § 32.1-137.9, including the criteria used and the clinical reason for the adverse determination and the alternate length of treatment of the alternate treatment setting or settings, if any, that the entity deems to be appropriate, and (ii) notified verbally at the time of the determination of the reconsideration of the adverse determination of the process for an appeal of the determination pursuant to § 32.1-137.15 and the contact name, address, and telephone number to file and perfect an appeal. If the treating provider on behalf of the covered person requests that the adverse determination be reviewed by a peer of the treating provider at any time during the reconsideration process, the request for reconsideration shall be vacated and considered an appeal pursuant to § 32.1-137.15. In such cases, the covered person shall be notified that the reconsideration has been vacated and an appeal initiated, all documentation and information provided or relied upon during the reconsideration process pursuant to this section shall be converted to the appeal process, and no additional actions shall be required of the treating provider to perfect the appeal.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":248647,"text":"Any reconsideration shall be rendered and the determination provided to the treating provider and the covered person in writing within 10 working days of receipt of the request for reconsideration.","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}],"previous_section":{"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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.14\/","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 2 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 2010, chapter 395<\/a>; in 2011, chapter 788<\/a>.<\/p>","references":[{"id":56529,"section_number":"32.1-137.10","catch_line":"Utilization review plan required","order_by":null,"url":"\/32.1-137.10\/"},{"id":64658,"section_number":"32.1-137.13","catch_line":"Adverse determination","order_by":null,"url":"\/32.1-137.13\/"},{"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":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":203139,"object_type":"law","relational_id":68683,"identifier":"32.1-137.14","token":"32.1\/5\/1.2\/32.1-137.14","url":"\/32.1-137.14\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.14\/","token":"32.1\/5\/1.2\/32.1-137.14","dublin_core":{"Title":"Reconsideration of adverse determination","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.14","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> A treating provider may request reconsideration of an adverse determination<\/span> pursuant to this section or may appeal<\/span> an adverse determination<\/span> pursuant to § 32.1-137.15<\/a>. Any reconsideration of an adverse determination<\/span> shall only be requested by the treating provider on behalf of the covered person<\/span>. A determination on reconsideration shall be made by a physician advisor<\/span>, peer of the treating health care provider<\/span><\/span>, or a panel<\/span> of other appropriate health care providers<\/span> with at least one physician advisor<\/span> or peer of the treating health care provider<\/span><\/span> on the panel<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The treating provider on behalf of the covered person<\/span> shall be (i) notified verbally at the time of the determination of the reconsideration of the adverse determination<\/span> and in writing following the determination of the reconsideration of the adverse determination<\/span>, in accordance with § 32.1-137.9<\/a>, including the criteria used and the clinical reason for the adverse determination<\/span> and the alternate length of treatment of the alternate treatment setting or settings, if any, that the entity<\/span> deems to be appropriate, and (ii) notified verbally at the time of the determination of the reconsideration of the adverse determination<\/span> of the process for an appeal<\/span> of the determination pursuant to § 32.1-137.15<\/a> and the contact name, address, and telephone number to file and perfect an appeal<\/span>. If the treating provider on behalf of the covered person<\/span> requests that the adverse determination<\/span> be reviewed by a peer of the treating provider at any time during the reconsideration process, the request for reconsideration shall be vacated and considered an appeal<\/span> pursuant to § 32.1-137.15<\/a>. In such cases, the covered person<\/span> shall be notified that the reconsideration has been vacated and an appeal<\/span> initiated, all documentation and information provided or relied upon during the reconsideration process pursuant to this section shall be converted to the appeal<\/span> process, and no additional actions shall be required of the treating provider to perfect the appeal<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Any reconsideration shall be rendered and the determination provided to the treating provider and the covered person<\/span> in writing within 10 working days of receipt of the request for reconsideration. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nRECONSIDERATION OF ADVERSE DETERMINATION (\u00a7 32.1-137.14)\n\nA. A treating provider may request reconsideration of an adverse determination\npursuant to this section or may appeal an adverse determination pursuant to\n§ 32.1-137.15. Any reconsideration of an adverse determination shall only\nbe requested by the treating provider on behalf of the covered person. A\ndetermination on reconsideration shall be made by a physician advisor, peer of\nthe treating health care provider, or a panel of other appropriate health care\nproviders with at least one physician advisor or peer of the treating health\ncare provider on the panel.\n\nB. The treating provider on behalf of the covered person shall be (i) notified\nverbally at the time of the determination of the reconsideration of the adverse\ndetermination and in writing following the determination of the reconsideration\nof the adverse determination, in accordance with § 32.1-137.9, including\nthe criteria used and the clinical reason for the adverse determination and the\nalternate length of treatment of the alternate treatment setting or settings, if\nany, that the entity deems to be appropriate, and (ii) notified verbally at the\ntime of the determination of the reconsideration of the adverse determination of\nthe process for an appeal of the determination pursuant to § 32.1-137.15\nand the contact name, address, and telephone number to file and perfect an\nappeal. If the treating provider on behalf of the covered person requests that\nthe adverse determination be reviewed by a peer of the treating provider at any\ntime during the reconsideration process, the request for reconsideration shall\nbe vacated and considered an appeal pursuant to § 32.1-137.15. In such\ncases, the covered person shall be notified that the reconsideration has been\nvacated and an appeal initiated, all documentation and information provided or\nrelied upon during the reconsideration process pursuant to this section shall be\nconverted to the appeal process, and no additional actions shall be required of\nthe treating provider to perfect the appeal.\n\nC. Any reconsideration shall be rendered and the determination provided to the\ntreating provider and the covered person in writing within 10 working days of\nreceipt of the request for reconsideration.\n\nHISTORY: 1998, c. 891; 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}}