{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.9.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.9.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.9.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.9.html"}],"law_id":59792,"edition_id":1,"section_id":59792,"structure_id":14765,"section_number":"32.1-137.9","catch_line":"Requirements and standards for utilization review entities","history":"1998, c. 891; 2011, c. 788.","full_text":"A\n\nEach entity shall establish reasonable and prudent standards and criteria to be applied in utilization review determinations with input from physician advisors representing major areas of specialty and certified by the boards of the various American medical specialties. Such standards shall be objective, clinically valid, and compatible with established principles of health care. Such standards shall further be established so as to be sufficiently flexible to allow deviations from norms when justified on case-by-case bases.\n\t\t\tThe entity shall make available to any provider or covered person, upon written request, a list of such physician advisors and their major areas of specialty, as well as the standards and criteria established in accordance with this section except as prohibited in accordance with copyright laws.B\n\nAn adverse determination shall be made only in accordance with § 32.1-137.13.C\n\nEach entity shall have a process for reconsideration of an adverse determination in accordance with § 32.1-137.14 and an appeals process in accordance with § 32.1-137.15.D\n\nEach entity shall make arrangements to use the services of physician advisors who are specialists in the various categories of health care on “per need” or “as needed” bases in conducting utilization review.E\n\nEach entity shall have review staff who are properly qualified, trained and supervised, and supported by a physician advisor, to carry out its review determinations.F\n\nEach entity shall notify its covered persons of the review process, including the appeals process, and shall so notify the covered person’s provider upon written request by the provider. An Evidence of Coverage shall contain a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of the process for reconsideration of an adverse determination rendered under § 32.1-137.13, as required by § 32.1-137.14, and the process for internal appeal from an adverse determination under § 32.1-137.15.G\n\nEach entity shall communicate its utilization review decision no later than two business days after receipt by the entity of all information necessary to complete the review.H\n\nEach entity shall have a representative, authorized to approve utilization review determinations, available to covered persons and providers in accordance with § 32.1-137.11.I\n\nThe Commissioner shall have the right to determine that an entity has complied with the requirement that the entity establish reasonable and prudent requirements and standards pursuant to this section.","order_by":null,"text":{"0":{"id":218966,"text":"Each entity shall establish reasonable and prudent standards and criteria to be applied in utilization review determinations with input from physician advisors representing major areas of specialty and certified by the boards of the various American medical specialties. Such standards shall be objective, clinically valid, and compatible with established principles of health care. Such standards shall further be established so as to be sufficiently flexible to allow deviations from norms when justified on case-by-case bases.\n\t\t\tThe entity shall make available to any provider or covered person, upon written request, a list of such physician advisors and their major areas of specialty, as well as the standards and criteria established in accordance with this section except as prohibited in accordance with copyright laws.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":218967,"text":"An adverse determination shall be made only in accordance with § 32.1-137.13.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":218968,"text":"Each entity shall have a process for reconsideration of an adverse determination in accordance with § 32.1-137.14 and an appeals process in accordance with § 32.1-137.15.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":218969,"text":"Each entity shall make arrangements to use the services of physician advisors who are specialists in the various categories of health care on “per need” or “as needed” bases in conducting utilization review.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":218970,"text":"Each entity shall have review staff who are properly qualified, trained and supervised, and supported by a physician advisor, to carry out its review determinations.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":218971,"text":"Each entity shall notify its covered persons of the review process, including the appeals process, and shall so notify the covered person’s provider upon written request by the provider. An Evidence of Coverage shall contain a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of the process for reconsideration of an adverse determination rendered under § 32.1-137.13, as required by § 32.1-137.14, and the process for internal appeal from an adverse determination under § 32.1-137.15.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":218972,"text":"Each entity shall communicate its utilization review decision no later than two business days after receipt by the entity of all information necessary to complete the review.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":218973,"text":"Each entity shall have a representative, authorized to approve utilization review determinations, available to covered persons and providers in accordance with § 32.1-137.11.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"8":{"id":218974,"text":"The Commissioner shall have the right to determine that an entity has complied with the requirement that the entity establish reasonable and prudent requirements and standards pursuant to this section.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H"}},"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":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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.9\/","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 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":68683,"section_number":"32.1-137.14","catch_line":"Reconsideration of adverse determination","order_by":null,"url":"\/32.1-137.14\/"},{"id":80679,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","order_by":null,"url":"\/32.1-137.2\/"}],"refers_to":[{"id":64658,"section_number":"32.1-137.13","catch_line":"Adverse determination","order_by":null,"url":"\/32.1-137.13\/"},{"id":68683,"section_number":"32.1-137.14","catch_line":"Reconsideration of adverse determination","order_by":null,"url":"\/32.1-137.14\/"}],"permalink":{"id":203163,"object_type":"law","relational_id":59792,"identifier":"32.1-137.9","token":"32.1\/5\/1.2\/32.1-137.9","url":"\/32.1-137.9\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.9\/","token":"32.1\/5\/1.2\/32.1-137.9","dublin_core":{"Title":"Requirements and standards for utilization review entities","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.9","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each entity<\/span> shall establish reasonable and prudent standards and criteria to be applied in utilization review<\/span> determinations with input from physician advisors<\/span> representing major areas of specialty and certified by the boards<\/span> of the various American medical specialties. Such standards shall be objective, clinically valid, and compatible with established principles of health care. Such standards shall further be established so as to be sufficiently flexible to allow deviations from norms when justified on case-by-case bases.\n\t\t\tThe entity<\/span> shall make available to any provider<\/span> or covered person<\/span>, upon written request, a list of such physician advisors<\/span> and their major areas of specialty, as well as the standards and criteria established in accordance with this section except as prohibited in accordance with copyright laws<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> An adverse determination<\/span> shall be made only in accordance with § 32.1-137.13<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Each entity<\/span> shall have a process for reconsideration of an adverse determination<\/span> in accordance with § 32.1-137.14<\/a> and an appeals<\/span> process in accordance with § 32.1-137.15<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Each entity<\/span> shall make arrangements to use the services of physician advisors<\/span> who are specialists in the various categories of health care on “per need” or “as needed” bases in conducting utilization review<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Each entity<\/span> shall have review staff who are properly qualified, trained and supervised, and supported by a physician advisor<\/span>, to carry out its review determinations. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> Each entity<\/span> shall notify its covered persons<\/span> of the review process, including the appeals<\/span> process, and shall so notify the covered person<\/span>’s provider<\/span> upon written request by the provider<\/span>. An Evidence of Coverage<\/span> shall contain a clear and complete statement, if a contract<\/span>, or a reasonably complete summary, if a certificate, of the process for reconsideration of an adverse determination<\/span> rendered under § 32.1-137.13<\/a>, as required by § 32.1-137.14<\/a>, and the process for internal appeal<\/span> from an adverse determination<\/span> under § 32.1-137.15<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> Each entity<\/span> shall communicate its utilization review<\/span> decision no later than two business days after receipt by the entity<\/span> of all information necessary to complete the review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Each entity<\/span> shall have a representative, authorized to approve utilization review<\/span> determinations, available to covered persons<\/span> and providers<\/span> in accordance with § 32.1-137.11<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> The Commissioner<\/span> shall have the right to determine that an entity<\/span> has complied with the requirement that the entity<\/span> establish reasonable and prudent requirements and standards pursuant to this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nREQUIREMENTS AND STANDARDS FOR UTILIZATION REVIEW ENTITIES (\u00a7 32.1-137.9)\n\nA. Each entity shall establish reasonable and prudent standards and criteria to\nbe applied in utilization review determinations with input from physician\nadvisors representing major areas of specialty and certified by the boards of\nthe various American medical specialties. Such standards shall be objective,\nclinically valid, and compatible with established principles of health care.\nSuch standards shall further be established so as to be sufficiently flexible to\nallow deviations from norms when justified on case-by-case bases.\n\t\t\tThe entity shall make available to any provider or covered person, upon\nwritten request, a list of such physician advisors and their major areas of\nspecialty, as well as the standards and criteria established in accordance with\nthis section except as prohibited in accordance with copyright laws.\n\nB. An adverse determination shall be made only in accordance with §\n32.1-137.13.\n\nC. Each entity shall have a process for reconsideration of an adverse\ndetermination in accordance with § 32.1-137.14 and an appeals process in\naccordance with § 32.1-137.15.\n\nD. Each entity shall make arrangements to use the services of physician advisors\nwho are specialists in the various categories of health care on “per\nneed” or “as needed” bases in conducting utilization review.\n\nE. Each entity shall have review staff who are properly qualified, trained and\nsupervised, and supported by a physician advisor, to carry out its review\ndeterminations.\n\nF. Each entity shall notify its covered persons of the review process, including\nthe appeals process, and shall so notify the covered person’s provider\nupon written request by the provider. An Evidence of Coverage shall contain a\nclear and complete statement, if a contract, or a reasonably complete summary,\nif a certificate, of the process for reconsideration of an adverse determination\nrendered under § 32.1-137.13, as required by § 32.1-137.14, and the\nprocess for internal appeal from an adverse determination under §\n32.1-137.15.\n\nG. Each entity shall communicate its utilization review decision no later than\ntwo business days after receipt by the entity of all information necessary to\ncomplete the review.\n\nH. Each entity shall have a representative, authorized to approve utilization\nreview determinations, available to covered persons and providers in accordance\nwith § 32.1-137.11.\n\nI. The Commissioner shall have the right to determine that an entity has\ncomplied with the requirement that the entity establish reasonable and prudent\nrequirements and standards pursuant to this section.\n\nHISTORY: 1998, c. 891; 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}}