{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3558.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3558.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3558.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3558.html"}],"law_id":56843,"edition_id":1,"section_id":56843,"structure_id":14588,"section_number":"38.2-3558","catch_line":"Health carrier’s internal appeal process","history":"2011, c. 788.","full_text":"Each health carrier shall establish an internal appeal process, including a process for urgent care appeals, to consider a utilization review adverse determination or other adverse benefit determination or decision that is appealed by a covered person, his authorized representative, or his provider. The Commission shall promulgate regulations effectuating the purpose of this section, including timeframes for filing appeals, types of claims that may be appealed including rescissions, notice requirements, rights of the covered person, and reviewer requirements.","order_by":null,"text":{"0":{"id":208219,"text":"Each health carrier shall establish an internal appeal process, including a process for urgent care appeals, to consider a utilization review adverse determination or other adverse benefit determination or decision that is appealed by a covered person, his authorized representative, or his provider. The Commission shall promulgate regulations effectuating the purpose of this section, including timeframes for filing appeals, types of claims that may be appealed including rescissions, notice requirements, rights of the covered person, and reviewer requirements.","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}],"previous_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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3558\/","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":57196,"section_number":"32.1-137.15","catch_line":"Adverse determination; appeal","order_by":null,"url":"\/32.1-137.15\/"}],"refers_to":false,"permalink":{"id":215947,"object_type":"law","relational_id":56843,"identifier":"38.2-3558","token":"38.2\/35.1\/38.2-3558","url":"\/38.2-3558\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3558\/","token":"38.2\/35.1\/38.2-3558","dublin_core":{"Title":"Health carrier’s internal appeal process","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3558","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

Each health carrier<\/span> shall establish an internal appeal<\/span> process, including a process for urgent care appeals<\/span>, to consider a utilization review<\/span> adverse determination<\/span> or other adverse benefit determination or decision that is appealed by a covered person<\/span>, his authorized representative<\/span>, or his provider<\/span>. The Commission<\/span> shall promulgate regulations effectuating the purpose of this section, including timeframes for filing appeals<\/span>, types of claims that may be appealed including rescissions, notice requirements, rights of the covered person<\/span>, and reviewer requirements.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nHEALTH CARRIER’S INTERNAL APPEAL PROCESS (\u00a7 38.2-3558)\n\nEach health carrier shall establish an internal appeal process, including a\nprocess for urgent care appeals, to consider a utilization review adverse\ndetermination or other adverse benefit determination or decision that is\nappealed by a covered person, his authorized representative, or his provider.\nThe Commission shall promulgate regulations effectuating the purpose of this\nsection, including timeframes for filing appeals, types of claims that may be\nappealed including rescissions, notice requirements, rights of the covered\nperson, and reviewer requirements.\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}}