{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-138.6.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-138.6.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-138.6.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-138.6.html"}],"law_id":63369,"edition_id":1,"section_id":63369,"structure_id":13616,"section_number":"32.1-138.6","catch_line":"Definitions","history":"1990, c. 826, \u00a7 38.2-5300; 1995, c. 745; 1996, c. 259; 1998, c. 129; 2000, c. 564.","full_text":"In this chapter the following terms have the meanings indicated:\n\t\t“Certificate of registration” means a certificate of registration granted by the Department of Health to a private review agent.\n\t\t“Medical director” means a physician licensed to practice medicine in the Commonwealth of Virginia who is an employee of a utilization review organization responsible for compliance with the provisions of this article.\n\t\t“Physician advisor” means a physician licensed to practice medicine in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States who provides medical advice or information to a private review agent or a utilization review entity in connection with its utilization review activities.\n\t\t“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:\n\n1\n\nA health maintenance organization authorized to transact business in Virginia; or2\n\nA health insurer, hospital service corporation, health services plan or preferred provider organization authorized to offer health benefits in this Commonwealth.\n\t\t\t“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 purposes of this article, “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, 38.2-118, 38.2-119, 38.2-124, 38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132 and 38.2-134.\n\t\t\t“Utilization review program” means a program for conducting utilization reviews by a private review agent.","order_by":null,"text":{"0":{"id":230912,"text":"In this chapter the following terms have the meanings indicated:\n\t\t“Certificate of registration” means a certificate of registration granted by the Department of Health to a private review agent.\n\t\t“Medical director” means a physician licensed to practice medicine in the Commonwealth of Virginia who is an employee of a utilization review organization responsible for compliance with the provisions of this article.\n\t\t“Physician advisor” means a physician licensed to practice medicine in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States who provides medical advice or information to a private review agent or a utilization review entity in connection with its utilization review activities.\n\t\t“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:","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1,"next_prefix":"1"},"1":{"id":230913,"text":"A health maintenance organization authorized to transact business in Virginia; or","type":"section","prefixes":["1"],"prefix":"1","entire_prefix":"1","prefix_anchor":"1","level":1,"prior_prefix":"","next_prefix":"2"},"2":{"id":230914,"text":"A health insurer, hospital service corporation, health services plan or preferred provider organization authorized to offer health benefits in this Commonwealth.\n\t\t\t“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 purposes of this article, “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, 38.2-118, 38.2-119, 38.2-124, 38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132 and 38.2-134.\n\t\t\t“Utilization review program” means a program for conducting utilization reviews by a private review agent.","type":"section","prefixes":["2"],"prefix":"2","entire_prefix":"2","prefix_anchor":"2","level":1,"prior_prefix":"1"}},"ancestry":[{"id":13616,"edition_id":1,"name":"Private Review Agents","identifier":"2.1","label":"article","depth":3,"order_by":1,"parent_id":12728,"metadata":{},"date_created":"2026-06-26 03:45:23","date_modified":"2026-06-26 03:45:23","permalink":{"id":203197,"object_type":"structure","relational_id":13616,"identifier":"2.1","token":"32.1\/5\/2.1","url":"\/32.1\/5\/2.1\/","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":74883,"structure_id":13616,"section_number":"32.1-138.10","catch_line":"Expiration; renewal","url":"\/32.1-138.10\/","token":"32.1\/5\/2.1\/32.1-138.10","metadata":false},{"id":69661,"structure_id":13616,"section_number":"32.1-138.11","catch_line":"Denial; revocation","url":"\/32.1-138.11\/","token":"32.1\/5\/2.1\/32.1-138.11","metadata":false},{"id":54583,"structure_id":13616,"section_number":"32.1-138.12","catch_line":"Waiver of requirements of article","url":"\/32.1-138.12\/","token":"32.1\/5\/2.1\/32.1-138.12","metadata":false},{"id":73931,"structure_id":13616,"section_number":"32.1-138.13","catch_line":"Access to and confidentiality of patient-specific medical records and information","url":"\/32.1-138.13\/","token":"32.1\/5\/2.1\/32.1-138.13","metadata":false},{"id":63195,"structure_id":13616,"section_number":"32.1-138.14","catch_line":"No private right of action created","url":"\/32.1-138.14\/","token":"32.1\/5\/2.1\/32.1-138.14","metadata":false},{"id":66986,"structure_id":13616,"section_number":"32.1-138.15","catch_line":"Regulations","url":"\/32.1-138.15\/","token":"32.1\/5\/2.1\/32.1-138.15","metadata":false},{"id":63369,"structure_id":13616,"section_number":"32.1-138.6","catch_line":"Definitions","url":"\/32.1-138.6\/","token":"32.1\/5\/2.1\/32.1-138.6","metadata":false},{"id":75335,"structure_id":13616,"section_number":"32.1-138.7","catch_line":"Certificates of registration required; issuance; transferability; regulations","url":"\/32.1-138.7\/","token":"32.1\/5\/2.1\/32.1-138.7","metadata":false},{"id":67769,"structure_id":13616,"section_number":"32.1-138.8","catch_line":"Consultation with health regulatory boards","url":"\/32.1-138.8\/","token":"32.1\/5\/2.1\/32.1-138.8","metadata":false},{"id":56657,"structure_id":13616,"section_number":"32.1-138.9","catch_line":"Standards for approval","url":"\/32.1-138.9\/","token":"32.1\/5\/2.1\/32.1-138.9","metadata":false}],"previous_section":{"id":66986,"structure_id":13616,"section_number":"32.1-138.15","catch_line":"Regulations","url":"\/32.1-138.15\/","token":"32.1\/5\/2.1\/32.1-138.15","metadata":false},"next_section":{"id":75335,"structure_id":13616,"section_number":"32.1-138.7","catch_line":"Certificates of registration required; issuance; transferability; regulations","url":"\/32.1-138.7\/","token":"32.1\/5\/2.1\/32.1-138.7","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-138.6\/","history_text":"

This law was first created in 1990. The record of its establishment is cataloged in chapter 826 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. Unfortunately, the 1990 \u201cActs\u201d aren\u2019t available online. 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 1995, chapter 745<\/a>; in 1996, chapter 259<\/a>; in 1998, chapter 129<\/a>; in 2000, chapter 564<\/a>.<\/p>","references":[{"id":78307,"section_number":"32.1-137.8","catch_line":"Application to and compliance by utilization review entities","order_by":null,"url":"\/32.1-137.8\/"}],"refers_to":[{"id":83683,"section_number":"38.2-117","catch_line":"Personal injury liability","order_by":null,"url":"\/38.2-117\/"},{"id":58741,"section_number":"38.2-118","catch_line":"Property damage liability","order_by":null,"url":"\/38.2-118\/"},{"id":80898,"section_number":"38.2-119","catch_line":"Workers' compensation and employers' liability","order_by":null,"url":"\/38.2-119\/"},{"id":66976,"section_number":"38.2-124","catch_line":"Motor vehicle","order_by":null,"url":"\/38.2-124\/"},{"id":66153,"section_number":"38.2-125","catch_line":"Aircraft","order_by":null,"url":"\/38.2-125\/"},{"id":63990,"section_number":"38.2-126","catch_line":"Marine","order_by":null,"url":"\/38.2-126\/"},{"id":75005,"section_number":"38.2-130","catch_line":"Homeowners insurance","order_by":null,"url":"\/38.2-130\/"},{"id":79979,"section_number":"38.2-131","catch_line":"Farmowners insurance","order_by":null,"url":"\/38.2-131\/"},{"id":60601,"section_number":"38.2-132","catch_line":"Commercial multi-peril insurance","order_by":null,"url":"\/38.2-132\/"},{"id":74943,"section_number":"38.2-134","catch_line":"Definitions to include other insurance of same general kind","order_by":null,"url":"\/38.2-134\/"}],"permalink":{"id":203223,"object_type":"law","relational_id":63369,"identifier":"32.1-138.6","token":"32.1\/5\/2.1\/32.1-138.6","url":"\/32.1-138.6\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-138.6\/","token":"32.1\/5\/2.1\/32.1-138.6","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-138.6","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

In this chapter the following terms have the meanings indicated:\n\t\t“Certificate of registration<\/span>” means a certificate of registration<\/span> granted by the Department<\/span> of Health to a private review agent<\/span>.\n\t\t“Medical director<\/span>” means a physician licensed to practice medicine in the Commonwealth of Virginia who is an employee of a utilization review<\/span> organization responsible for compliance with the provisions of this article.\n\t\t“Physician advisor<\/span>” means a physician licensed to practice medicine in the Commonwealth of Virginia or under a comparable licensing law<\/span> of a state of the United States who provides medical advice or information to a private review agent<\/span> or a utilization review<\/span> entity in connection with its utilization review<\/span> activities.\n\t\t“Private review agent<\/span>” means a person<\/span> or entity performing utilization reviews<\/span>, except that the term shall not include the following entities or employees of any such entity so long as they conduct utilization reviews<\/span> solely for subscribers, policyholders, members or enrollees:<\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A health maintenance organization authorized to transact business in Virginia; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A health insurer, hospital service corporation, health services plan or preferred provider organization authorized to offer health benefits in this Commonwealth.\n\t\t\t“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<\/span>. For purposes of this article, “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<\/span> concerning insurance contract<\/span> 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<\/span> of insurance covering any classes of insurance defined in §§ 38.2-117<\/a>, 38.2-118<\/a>, 38.2-119<\/a>, 38.2-124<\/a>, 38.2-125<\/a>, 38.2-126<\/a>, 38.2-130<\/a>, 38.2-131<\/a>, 38.2-132<\/a> and 38.2-134<\/a>.\n\t\t\t“Utilization review program<\/span>” means a program for conducting utilization reviews<\/span> by a private review agent<\/span>. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 32.1-138.6)\n\nIn this chapter the following terms have the meanings indicated:\n\t\t“Certificate of registration” means a certificate of registration\ngranted by the Department of Health to a private review agent.\n\t\t“Medical director” means a physician licensed to practice medicine\nin the Commonwealth of Virginia who is an employee of a utilization review\norganization responsible for compliance with the provisions of this article.\n\t\t“Physician advisor” means a physician licensed to practice\nmedicine in the Commonwealth of Virginia or under a comparable licensing law of\na state of the United States who provides medical advice or information to a\nprivate review agent or a utilization review entity in connection with its\nutilization review activities.\n\t\t“Private review agent” means a person or entity performing\nutilization reviews, except that the term shall not include the following\nentities or employees of any such entity so long as they conduct utilization\nreviews solely for subscribers, policyholders, members or enrollees:\n\n1. A health maintenance organization authorized to transact business in\nVirginia; or\n\n2. A health insurer, hospital service corporation, health services plan or\npreferred provider organization authorized to offer health benefits in this\nCommonwealth.\n\t\t\t“Utilization review” means a system for reviewing the necessity,\nappropriateness and efficiency of hospital, medical or other health care\nresources rendered or proposed to be rendered to a patient or group of patients\nfor the purpose of determining whether such services should be covered or\nprovided by an insurer, health services plan, health maintenance organization,\nor other entity or person. For purposes of this article, “utilization\nreview” shall include, but not be limited to, preadmission, concurrent and\nretrospective medical necessity determination, and review related to the\nappropriateness of the site at which services were or are to be delivered.\n“Utilization review” shall not include (i) any review of issues\nconcerning insurance contract coverage or contractual restrictions on facilities\nto be used for the provision of services, (ii) any review of patient information\nby an employee of or consultant to any licensed hospital for patients of such\nhospital, or (iii) any determination by an insurer as to the reasonableness and\nnecessity of services for the treatment and care of an injury suffered by an\ninsured for which reimbursement is claimed under a contract of insurance\ncovering any classes of insurance defined in §§ 38.2-117, 38.2-118,\n38.2-119, 38.2-124, 38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132 and\n38.2-134.\n\t\t\t“Utilization review program” means a program for conducting\nutilization reviews by a private review agent.\n\nHISTORY: 1990, c. 826, \u00a7 38.2-5300; 1995, c. 745; 1996, c. 259; 1998, c. 129;\n2000, c. 564.","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}}