{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3556.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3556.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3556.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3556.html"}],"law_id":58140,"edition_id":1,"section_id":58140,"structure_id":14588,"section_number":"38.2-3556","catch_line":"Definitions","history":"2011, c. 788.","full_text":"As used in this chapter, unless the context requires a different meaning:\n\t\t“Adverse determination” means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated.\n\t\t“Ambulatory review” means utilization review of health care services performed or provided in an outpatient setting.\n\t\t“Authorized representative” means (i) a person to whom a covered person has given express written consent to represent the covered person in an external review, (ii) a person authorized by law to provide substituted consent for a covered person, or (iii) a family member of the covered person or the covered person’s treating health care professional only when the covered person is unable to provide consent.\n\t\t“Best evidence” means evidence based on (i) randomized clinical trials; if randomized clinical trials are not available, then (ii) cohort studies or case-control studies; if clauses (i) and (ii) are not available, then (iii) case-series; or if clauses (i), (ii), and (iii) are not available, then (iv) expert opinion.\n\t\t“Case-control study” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.\n\t\t“Case management” means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.\n\t\t“Case-series” means an evaluation of a series of patients with a particular outcome, without the use of a control group.\n\t\t“Certification” means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.\n\t\t“Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.\n\t\t“Cohort study” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention.\n\t\t“Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.\n\t\t“Covered benefits” or “benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.\n\t\t“Discharge planning” means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.\n\t\t“Emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.\n\t\t“Emergency services” means health care items and services furnished or required to evaluate and treat an emergency medical condition.\n\t\t“Evidence-based standard” means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients.\n\t\t“Expert opinion” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.\n\t\t“Facility” means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Final adverse determination” means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review entity, at the completion of the health carrier’s internal appeal process.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.\n\t\t“Health care professional” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the laws of the Commonwealth.\n\t\t“Health care provider” or “provider” means a health care professional or a facility.\n\t\t“Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier” means an entity, subject to the insurance laws and regulations of the Commonwealth or subject to the jurisdiction of the Commission, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an accident and sickness insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or any other entity providing a plan of health insurance, health benefits, or health care services except as excluded under \u00a7 38.2-3557.\n\t\t“Independent review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.\n\t\t“Medical or scientific evidence” means evidence found in (i) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (ii) peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medica (EMBASE); (iii) medical journals recognized by the Secretary of Health and Human Services under \u00a7 1861(t)(2) of the federal Social Security Act; (iv) the following standard reference compendia: the American Hospital Formulary Service Drug Information; Drug Facts and Comparisons; the American Dental Association Accepted Dental Therapeutics; the United States Pharmacopeia — Drug Information; National Comprehensive Cancer Network’s Drugs & Biologics Compendium; and Elsevier Gold Standard’s Clinical Pharmacology; (v) findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including the federal Agency for Healthcare Research and Quality, the National Institutes of Health, the National Cancer Institute, the National Academy of Sciences, the Centers for Medicare and Medicaid Services, the federal Food and Drug Administration, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or (vi) any other medical or scientific evidence that is comparable to the sources listed in clauses (i) through (v).\n\t\t“NAIC” means the National Association of Insurance Commissioners.\n\t\t“Prospective review” means utilization review conducted prior to an admission or a course of treatment.\n\t\t“Randomized clinical trial” means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention and includes study of the groups for variables and anticipated outcomes over time.\n\t\t“Retrospective review” means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.\n\t\t“Second opinion” means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service.\n\t\t“Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.\n\t\t“Utilization review entity” means an individual or entity that conducts utilization review.","order_by":null,"text":{"0":{"id":213012,"text":"As used in this chapter, unless the context requires a different meaning:\n\t\t“Adverse determination” means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated.\n\t\t“Ambulatory review” means utilization review of health care services performed or provided in an outpatient setting.\n\t\t“Authorized representative” means (i) a person to whom a covered person has given express written consent to represent the covered person in an external review, (ii) a person authorized by law to provide substituted consent for a covered person, or (iii) a family member of the covered person or the covered person’s treating health care professional only when the covered person is unable to provide consent.\n\t\t“Best evidence” means evidence based on (i) randomized clinical trials; if randomized clinical trials are not available, then (ii) cohort studies or case-control studies; if clauses (i) and (ii) are not available, then (iii) case-series; or if clauses (i), (ii), and (iii) are not available, then (iv) expert opinion.\n\t\t“Case-control study” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.\n\t\t“Case management” means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.\n\t\t“Case-series” means an evaluation of a series of patients with a particular outcome, without the use of a control group.\n\t\t“Certification” means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.\n\t\t“Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.\n\t\t“Cohort study” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention.\n\t\t“Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.\n\t\t“Covered benefits” or “benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.\n\t\t“Discharge planning” means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.\n\t\t“Emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.\n\t\t“Emergency services” means health care items and services furnished or required to evaluate and treat an emergency medical condition.\n\t\t“Evidence-based standard” means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients.\n\t\t“Expert opinion” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.\n\t\t“Facility” means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Final adverse determination” means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review entity, at the completion of the health carrier’s internal appeal process.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.\n\t\t“Health care professional” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the laws of the Commonwealth.\n\t\t“Health care provider” or “provider” means a health care professional or a facility.\n\t\t“Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier” means an entity, subject to the insurance laws and regulations of the Commonwealth or subject to the jurisdiction of the Commission, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an accident and sickness insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or any other entity providing a plan of health insurance, health benefits, or health care services except as excluded under \u00a7 38.2-3557.\n\t\t“Independent review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.\n\t\t“Medical or scientific evidence” means evidence found in (i) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (ii) peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medica (EMBASE); (iii) medical journals recognized by the Secretary of Health and Human Services under \u00a7 1861(t)(2) of the federal Social Security Act; (iv) the following standard reference compendia: the American Hospital Formulary Service Drug Information; Drug Facts and Comparisons; the American Dental Association Accepted Dental Therapeutics; the United States Pharmacopeia — Drug Information; National Comprehensive Cancer Network’s Drugs & Biologics Compendium; and Elsevier Gold Standard’s Clinical Pharmacology; (v) findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including the federal Agency for Healthcare Research and Quality, the National Institutes of Health, the National Cancer Institute, the National Academy of Sciences, the Centers for Medicare and Medicaid Services, the federal Food and Drug Administration, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or (vi) any other medical or scientific evidence that is comparable to the sources listed in clauses (i) through (v).\n\t\t“NAIC” means the National Association of Insurance Commissioners.\n\t\t“Prospective review” means utilization review conducted prior to an admission or a course of treatment.\n\t\t“Randomized clinical trial” means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention and includes study of the groups for variables and anticipated outcomes over time.\n\t\t“Retrospective review” means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.\n\t\t“Second opinion” means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service.\n\t\t“Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.\n\t\t“Utilization review entity” means an individual or entity that conducts utilization review.","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1}},"ancestry":[{"id":14588,"edition_id":1,"name":"Health Carrier Internal Appeal Process and External Review","identifier":"35.1","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:48:47","date_modified":"2026-06-26 03:48:47","permalink":{"id":215937,"object_type":"structure","relational_id":14588,"identifier":"35.1","token":"38.2\/35.1","url":"\/38.2\/35.1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":58140,"structure_id":14588,"section_number":"38.2-3556","catch_line":"Definitions","url":"\/38.2-3556\/","token":"38.2\/35.1\/38.2-3556","metadata":false},{"id":56086,"structure_id":14588,"section_number":"38.2-3557","catch_line":"Scope of chapter","url":"\/38.2-3557\/","token":"38.2\/35.1\/38.2-3557","metadata":false},{"id":56843,"structure_id":14588,"section_number":"38.2-3558","catch_line":"Health carrier's internal appeal process","url":"\/38.2-3558\/","token":"38.2\/35.1\/38.2-3558","metadata":false},{"id":77920,"structure_id":14588,"section_number":"38.2-3559","catch_line":"Notice of right to external review","url":"\/38.2-3559\/","token":"38.2\/35.1\/38.2-3559","metadata":false},{"id":65207,"structure_id":14588,"section_number":"38.2-3560","catch_line":"Exhaustion of internal appeal process","url":"\/38.2-3560\/","token":"38.2\/35.1\/38.2-3560","metadata":false},{"id":66856,"structure_id":14588,"section_number":"38.2-3561","catch_line":"Standard external review","url":"\/38.2-3561\/","token":"38.2\/35.1\/38.2-3561","metadata":false},{"id":83961,"structure_id":14588,"section_number":"38.2-3562","catch_line":"Expedited external review","url":"\/38.2-3562\/","token":"38.2\/35.1\/38.2-3562","metadata":false},{"id":63745,"structure_id":14588,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","url":"\/38.2-3563\/","token":"38.2\/35.1\/38.2-3563","metadata":false},{"id":78633,"structure_id":14588,"section_number":"38.2-3564","catch_line":"Binding nature of external review decision","url":"\/38.2-3564\/","token":"38.2\/35.1\/38.2-3564","metadata":false},{"id":63044,"structure_id":14588,"section_number":"38.2-3565","catch_line":"Minimum qualifications for independent review organizations","url":"\/38.2-3565\/","token":"38.2\/35.1\/38.2-3565","metadata":false},{"id":59040,"structure_id":14588,"section_number":"38.2-3566","catch_line":"Approval of independent review organizations","url":"\/38.2-3566\/","token":"38.2\/35.1\/38.2-3566","metadata":false},{"id":79665,"structure_id":14588,"section_number":"38.2-3567","catch_line":"Independent review organizations to be held harmless","url":"\/38.2-3567\/","token":"38.2\/35.1\/38.2-3567","metadata":false},{"id":81396,"structure_id":14588,"section_number":"38.2-3568","catch_line":"External review reporting requirements","url":"\/38.2-3568\/","token":"38.2\/35.1\/38.2-3568","metadata":false},{"id":75481,"structure_id":14588,"section_number":"38.2-3569","catch_line":"Funding of external review","url":"\/38.2-3569\/","token":"38.2\/35.1\/38.2-3569","metadata":false},{"id":83489,"structure_id":14588,"section_number":"38.2-3570","catch_line":"Disclosure requirements","url":"\/38.2-3570\/","token":"38.2\/35.1\/38.2-3570","metadata":false},{"id":56157,"structure_id":14588,"section_number":"38.2-3571","catch_line":"Regulations","url":"\/38.2-3571\/","token":"38.2\/35.1\/38.2-3571","metadata":false}],"next_section":{"id":56086,"structure_id":14588,"section_number":"38.2-3557","catch_line":"Scope of chapter","url":"\/38.2-3557\/","token":"38.2\/35.1\/38.2-3557","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3556\/","history_text":"

This law was first created in 2011. The record of its establishment is cataloged in chapter 788<\/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.<\/p>","references":[{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"}],"refers_to":[{"id":56086,"section_number":"38.2-3557","catch_line":"Scope of chapter","order_by":null,"url":"\/38.2-3557\/"}],"permalink":{"id":215939,"object_type":"law","relational_id":58140,"identifier":"38.2-3556","token":"38.2\/35.1\/38.2-3556","url":"\/38.2-3556\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3556\/","token":"38.2\/35.1\/38.2-3556","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3556","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

As used in this chapter, unless the context requires a different meaning:\n\t\t“Adverse determination” means a determination by a health carrier<\/span> or its designee utilization review entity<\/span> that an admission, availability of care, continued stay<\/span>, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier<\/span>’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated.\n\t\t“Ambulatory review<\/span>” means utilization review of health care services<\/span> performed or provided in an outpatient setting.\n\t\t“Authorized representative<\/span>” means (i) a person to whom a covered person<\/span> has given express written consent to represent the covered person<\/span> in an external review, (ii) a person authorized by law<\/span> to provide substituted consent for a covered person<\/span>, or (iii) a family member of the covered person<\/span> or the covered person<\/span>’s treating health care professional<\/span> only when the covered person<\/span> is unable to provide consent.\n\t\t“Best evidence<\/span>” means evidence based on (i) randomized clinical trials<\/span>; if randomized clinical trials<\/span> are not available, then (ii) cohort studies or case-control studies; if clauses (i) and (ii) are not available, then (iii) case-series<\/span>; or if clauses (i), (ii), and (iii) are not available, then (iv) expert opinion<\/span>.\n\t\t“Case-control study<\/span>” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.\n\t\t“Case management<\/span>” means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.\n\t\t“Case-series<\/span>” means an evaluation of a series of patients with a particular outcome, without the use of a control group.\n\t\t“Certification<\/span>” means a determination by a health carrier<\/span> or its designee utilization review entity<\/span> that an admission, availability of care, continued stay<\/span>, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier<\/span>’s requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.\n\t\t“Clinical review criteria<\/span>” means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier<\/span> to determine the necessity and appropriateness of health care services<\/span>.\n\t\t“Cohort study<\/span>” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention.\n\t\t“Concurrent review<\/span>” means utilization review conducted during a patient’s hospital stay<\/span> or course of treatment.\n\t\t“Covered benefits<\/span>” or “benefits” means those health care services<\/span> to which a covered person<\/span> is entitled under the terms of a health benefit plan<\/span>.\n\t\t“Covered person<\/span>” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan<\/span>.\n\t\t“Discharge planning<\/span>” means the formal process for determining, prior to discharge from a facility<\/span>, the coordination and management of the care that a patient receives following discharge from a facility<\/span>.\n\t\t“Emergency medical condition<\/span>” means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.\n\t\t“Emergency services<\/span>” means health care items and services furnished or required to evaluate and treat an emergency medical condition<\/span>.\n\t\t“Evidence-based standard<\/span>” means the conscientious, explicit, and judicious use of the current best evidence<\/span> based on the overall systematic review of the research in making decisions about the care of individual patients.\n\t\t“Expert opinion<\/span>” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.\n\t\t“Facility<\/span>” means an institution providing health care services<\/span> or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Final adverse determination<\/span>” means an adverse determination involving a covered benefit that has been upheld by a health carrier<\/span>, or its designee utilization review entity<\/span>, at the completion of the health carrier<\/span>’s internal appeal<\/span> process.\n\t\t“Health benefit plan<\/span>” means a policy, contract<\/span>, certificate, or agreement offered or issued by a health carrier<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services<\/span>.\n\t\t“Health care professional<\/span>” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services<\/span> consistent with the laws<\/span> of the Commonwealth.\n\t\t“Health care provider<\/span>” or “provider” means a health care professional<\/span> or a facility<\/span>.\n\t\t“Health care services<\/span>” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier<\/span>” means an entity, subject to the insurance laws<\/span> and regulations of the Commonwealth or subject to the jurisdiction<\/span> of the Commission<\/span>, that contracts<\/span> or offers to contract<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services<\/span>, including an accident and sickness insurance company<\/span>, a health maintenance organization, a nonprofit hospital and health service corporation, or a nonstock corporation offering or administering a health services plan<\/span>, a hospital services plan, or a medical or surgical services plan, or any other entity providing a plan of health insurance, health benefits, or health care services<\/span> except as excluded under \u00a7 38.2-3557<\/a>.\n\t\t“Independent review organization<\/span>” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations<\/span>.\n\t\t“Medical or scientific evidence<\/span>” means evidence found in (i) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (ii) peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medica (EMBASE); (iii) medical journals recognized by the Secretary of Health and Human Services under \u00a7 1861(t)(2) of the federal Social Security Act; (iv) the following standard reference compendia: the American Hospital Formulary Service Drug Information; Drug Facts<\/span> and Comparisons; the American Dental Association Accepted Dental Therapeutics; the United States<\/span> Pharmacopeia — Drug Information; National Comprehensive Cancer Network’s Drugs & Biologics Compendium; and Elsevier Gold Standard’s Clinical Pharmacology; (v) findings<\/span>, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including the federal Agency for Healthcare Research and Quality, the National Institutes of Health, the National Cancer Institute, the National Academy of Sciences, the Centers for Medicare<\/span> and Medicaid Services, the federal Food and Drug Administration, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services<\/span>; or (vi) any other medical or scientific evidence<\/span> that is comparable to the sources listed in clauses (i) through (v).\n\t\t“NAIC<\/span>” means the National Association of Insurance Commissioners<\/span>.\n\t\t“Prospective review<\/span>” means utilization review conducted prior to an admission or a course of treatment.\n\t\t“Randomized clinical trial<\/span>” means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention and includes study of the groups for variables and anticipated outcomes over time.\n\t\t“Retrospective review<\/span>” means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.\n\t\t“Second opinion<\/span>” means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service.\n\t\t“Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services<\/span>, procedures, or settings. Techniques may include ambulatory review<\/span>, prospective review<\/span>, second opinion<\/span>, certification<\/span>, concurrent review<\/span>, case management<\/span>, discharge planning<\/span>, or retrospective review<\/span>.\n\t\t“Utilization review entity<\/span>” means an individual or entity that conducts utilization review.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-3556)\n\nAs used in this chapter, unless the context requires a different meaning:\n\t\t“Adverse determination” means a determination by a health carrier\nor its designee utilization review entity that an admission, availability of\ncare, continued stay, or other health care service that is a covered benefit has\nbeen reviewed and, based upon the information provided, does not meet the health\ncarrier’s requirements for medical necessity, appropriateness, health care\nsetting, level of care, or effectiveness, and the requested service or payment\nfor the service is therefore denied, reduced, or terminated.\n\t\t“Ambulatory review” means utilization review of health care\nservices performed or provided in an outpatient setting.\n\t\t“Authorized representative” means (i) a person to whom a covered\nperson has given express written consent to represent the covered person in an\nexternal review, (ii) a person authorized by law to provide substituted consent\nfor a covered person, or (iii) a family member of the covered person or the\ncovered person’s treating health care professional only when the covered\nperson is unable to provide consent.\n\t\t“Best evidence” means evidence based on (i) randomized clinical\ntrials; if randomized clinical trials are not available, then (ii) cohort\nstudies or case-control studies; if clauses (i) and (ii) are not available, then\n(iii) case-series; or if clauses (i), (ii), and (iii) are not available, then\n(iv) expert opinion.\n\t\t“Case-control study” means a retrospective evaluation of two\ngroups of patients with different outcomes to determine which specific\ninterventions the patients received.\n\t\t“Case management” means a coordinated set of activities conducted\nfor individual patient management of serious, complicated, protracted, or other\nhealth conditions.\n\t\t“Case-series” means an evaluation of a series of patients with a\nparticular outcome, without the use of a control group.\n\t\t“Certification” means a determination by a health carrier or its\ndesignee utilization review entity that an admission, availability of care,\ncontinued stay, or other health care service has been reviewed and, based on the\ninformation provided, satisfies the health carrier’s requirements for\nmedical necessity, appropriateness, health care setting, level of care, and\neffectiveness.\n\t\t“Clinical review criteria” means the written screening procedures,\ndecision abstracts, clinical protocols, and practice guidelines used by a health\ncarrier to determine the necessity and appropriateness of health care services.\n\t\t“Cohort study” means a prospective evaluation of two groups of\npatients with only one group of patients receiving a specific intervention.\n\t\t“Concurrent review” means utilization review conducted during a\npatient’s hospital stay or course of treatment.\n\t\t“Covered benefits” or “benefits” means those health\ncare services to which a covered person is entitled under the terms of a health\nbenefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee, or\nother individual participating in a health benefit plan.\n\t\t“Discharge planning” means the formal process for determining,\nprior to discharge from a facility, the coordination and management of the care\nthat a patient receives following discharge from a facility.\n\t\t“Emergency medical condition” means the sudden and, at the time,\nunexpected onset of a health condition or illness that requires immediate\nmedical attention, where failure to provide medical attention would result in a\nserious impairment to bodily functions or a serious dysfunction of a bodily\norgan or part, or would place the person’s health in serious jeopardy.\n\t\t“Emergency services” means health care items and services\nfurnished or required to evaluate and treat an emergency medical condition.\n\t\t“Evidence-based standard” means the conscientious, explicit, and\njudicious use of the current best evidence based on the overall systematic\nreview of the research in making decisions about the care of individual\npatients.\n\t\t“Expert opinion” means a belief or an interpretation by\nspecialists with experience in a specific area about the scientific evidence\npertaining to a particular service, intervention, or therapy.\n\t\t“Facility” means an institution providing health care services or\na health care setting, including hospitals and other licensed inpatient centers;\nambulatory surgical or treatment centers; skilled nursing centers; residential\ntreatment centers; diagnostic, laboratory, and imaging centers; and\nrehabilitation and other therapeutic health settings.\n\t\t“Final adverse determination” means an adverse determination\ninvolving a covered benefit that has been upheld by a health carrier, or its\ndesignee utilization review entity, at the completion of the health\ncarrier’s internal appeal process.\n\t\t“Health benefit plan” means a policy, contract, certificate, or\nagreement offered or issued by a health carrier to provide, deliver, arrange\nfor, pay for, or reimburse any of the costs of health care services.\n\t\t“Health care professional” means a physician or other health care\npractitioner licensed, accredited, or certified to perform specified health care\nservices consistent with the laws of the Commonwealth.\n\t\t“Health care provider” or “provider” means a health\ncare professional or a facility.\n\t\t“Health care services” means services for the diagnosis,\nprevention, treatment, cure, or relief of a health condition, illness, injury,\nor disease.\n\t\t“Health carrier” means an entity, subject to the insurance laws\nand regulations of the Commonwealth or subject to the jurisdiction of the\nCommission, that contracts or offers to contract to provide, deliver, arrange\nfor, pay for, or reimburse any of the costs of health care services, including\nan accident and sickness insurance company, a health maintenance organization, a\nnonprofit hospital and health service corporation, or a nonstock corporation\noffering or administering a health services plan, a hospital services plan, or a\nmedical or surgical services plan, or any other entity providing a plan of\nhealth insurance, health benefits, or health care services except as excluded\nunder \u00a7 38.2-3557.\n\t\t“Independent review organization” means an entity that conducts\nindependent external reviews of adverse determinations and final adverse\ndeterminations.\n\t\t“Medical or scientific evidence” means evidence found in (i)\npeer-reviewed scientific studies published in or accepted for publication by\nmedical journals that meet nationally recognized requirements for scientific\nmanuscripts and that submit most of their published articles for review by\nexperts who are not part of the editorial staff; (ii) peer-reviewed medical\nliterature, including literature relating to therapies reviewed and approved by\na qualified institutional review board, biomedical compendia, and other medical\nliterature that meet the criteria of the National Institutes of Health’s\nLibrary of Medicine for indexing in Index Medicus (Medline) and Elsevier Science\nLtd. for indexing in Excerpta Medica (EMBASE); (iii) medical journals recognized\nby the Secretary of Health and Human Services under \u00a7 1861(t)(2) of the federal\nSocial Security Act; (iv) the following standard reference compendia: the\nAmerican Hospital Formulary Service Drug Information; Drug Facts and\nComparisons; the American Dental Association Accepted Dental Therapeutics; the\nUnited States Pharmacopeia — Drug Information; National Comprehensive\nCancer Network’s Drugs & Biologics Compendium; and Elsevier Gold\nStandard’s Clinical Pharmacology; (v) findings, studies, or research\nconducted by or under the auspices of federal government agencies and nationally\nrecognized federal research institutes, including the federal Agency for\nHealthcare Research and Quality, the National Institutes of Health, the National\nCancer Institute, the National Academy of Sciences, the Centers for Medicare and\nMedicaid Services, the federal Food and Drug Administration, and any national\nboard recognized by the National Institutes of Health for the purpose of\nevaluating the medical value of health care services; or (vi) any other medical\nor scientific evidence that is comparable to the sources listed in clauses (i)\nthrough (v).\n\t\t“NAIC” means the National Association of Insurance Commissioners.\n\t\t“Prospective review” means utilization review conducted prior to\nan admission or a course of treatment.\n\t\t“Randomized clinical trial” means a controlled, prospective study\nof patients that have been randomized into an experimental group and a control\ngroup at the beginning of the study with only the experimental group of patients\nreceiving a specific intervention and includes study of the groups for variables\nand anticipated outcomes over time.\n\t\t“Retrospective review” means a review of medical necessity\nconducted after services have been provided to a patient, but does not include\nthe review of a claim that is limited to an evaluation of reimbursement levels,\nveracity of documentation, accuracy of coding, or adjudication for payment.\n\t\t“Second opinion” means an opportunity or requirement to obtain a\nclinical evaluation by a provider other than the one originally making a\nrecommendation for a proposed health care service to assess the clinical\nnecessity and appropriateness of the initial proposed health care service.\n\t\t“Utilization review” means a set of formal techniques designed to\nmonitor the use of, or evaluate the clinical necessity, appropriateness,\nefficacy, or efficiency of, health care services, procedures, or settings.\nTechniques may include ambulatory review, prospective review, second opinion,\ncertification, concurrent review, case management, discharge planning, or\nretrospective review.\n\t\t“Utilization review entity” means an individual or entity that\nconducts utilization review.\n\nHISTORY: 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}}