{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3559.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3559.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3559.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3559.html"}],"law_id":77920,"edition_id":1,"section_id":77920,"structure_id":14588,"section_number":"38.2-3559","catch_line":"Notice of right to external review","history":"2011, c. 788; 2019, cc. 826, 840.","full_text":"A\n\nA health carrier shall notify the covered person in writing of an adverse determination or final adverse determination and the covered person’s right to request an external review. The notice of the right to request an external review shall include the following, or substantially similar, language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Commission.”B\n\nThe notice of the right to request an external review of an adverse determination shall include the following statements informing the covered person that:1\n\nIf the covered person’s adverse determination involves (i) cancer or (ii) a medical condition where the time frame for completion of an expedited internal appeal of an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3562;2\n\nIf the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3563;3\n\nIf the covered person or his authorized representative files a request for an expedited internal appeal with the health carrier, he may file at the same time a request for an expedited external review of an adverse determination pursuant to § 38.2-3562 or 38.2-3563. The independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited internal appeal prior to conducting the expedited external review; and4\n\nIf the covered person or his authorized representative files a standard appeal with the health carrier’s internal appeal process, and the health carrier does not issue a written decision within 30 days following the date the appeal requesting a review is filed and the covered person or his authorized representative did not request or agree to a delay, the covered person or his authorized representative may file a request for external review and shall be considered to have exhausted the health carrier’s internal appeal process.C\n\nThe notice of the right to request an external review of a final adverse determination shall include the following statements informing the covered person that:1\n\nIf the covered person has a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3562;2\n\nIf the final adverse determination involves an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or his authorized representative may request an expedited external review pursuant to § 38.2-3562; and3\n\nIf the final adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or his authorized representative may file a request for a standard external review pursuant to § 38.2-3563; or if the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or his authorized representative may request an expedited external review pursuant to subsection B of § 38.2-3563.D\n\nThe health carrier shall include the standard and expedited external review procedures and any forms with the notice of the right to an external review.","order_by":null,"text":{"0":{"id":279408,"text":"A health carrier shall notify the covered person in writing of an adverse determination or final adverse determination and the covered person’s right to request an external review. The notice of the right to request an external review shall include the following, or substantially similar, language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Commission.”","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":279409,"text":"The notice of the right to request an external review of an adverse determination shall include the following statements informing the covered person that:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":279410,"text":"If the covered person’s adverse determination involves (i) cancer or (ii) a medical condition where the time frame for completion of an expedited internal appeal of an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3562;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":279411,"text":"If the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3563;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":279412,"text":"If the covered person or his authorized representative files a request for an expedited internal appeal with the health carrier, he may file at the same time a request for an expedited external review of an adverse determination pursuant to § 38.2-3562 or 38.2-3563. The independent review organization assigned to conduct the expedited external review will determine whether the covered person shall be required to complete the expedited internal appeal prior to conducting the expedited external review; and","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":279413,"text":"If the covered person or his authorized representative files a standard appeal with the health carrier’s internal appeal process, and the health carrier does not issue a written decision within 30 days following the date the appeal requesting a review is filed and the covered person or his authorized representative did not request or agree to a delay, the covered person or his authorized representative may file a request for external review and shall be considered to have exhausted the health carrier’s internal appeal process.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"C"},"6":{"id":279414,"text":"The notice of the right to request an external review of a final adverse determination shall include the following statements informing the covered person that:","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B4","next_prefix":"C1"},"7":{"id":279415,"text":"If the covered person has a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or his authorized representative may file a request for an expedited external review pursuant to § 38.2-3562;","type":"section","prefixes":["C","1"],"prefix":"1","entire_prefix":"C1","prefix_anchor":"C1","level":2,"prior_prefix":"C","next_prefix":"C2"},"8":{"id":279416,"text":"If the final adverse determination involves an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or his authorized representative may request an expedited external review pursuant to § 38.2-3562; and","type":"section","prefixes":["C","2"],"prefix":"2","entire_prefix":"C2","prefix_anchor":"C2","level":2,"prior_prefix":"C1","next_prefix":"C3"},"9":{"id":279417,"text":"If the final adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person or his authorized representative may file a request for a standard external review pursuant to § 38.2-3563; or if the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or his authorized representative may request an expedited external review pursuant to subsection B of § 38.2-3563.","type":"section","prefixes":["C","3"],"prefix":"3","entire_prefix":"C3","prefix_anchor":"C3","level":2,"prior_prefix":"C2","next_prefix":"D"},"10":{"id":279418,"text":"The health carrier shall include the standard and expedited external review procedures and any forms with the notice of the right to an external review.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C3"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3559\/","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. 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 2019, chapters 826<\/a> and 840<\/a>.<\/p>","references":false,"refers_to":[{"id":83961,"section_number":"38.2-3562","catch_line":"Expedited external review","order_by":null,"url":"\/38.2-3562\/"},{"id":63745,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","order_by":null,"url":"\/38.2-3563\/"}],"permalink":{"id":215951,"object_type":"law","relational_id":77920,"identifier":"38.2-3559","token":"38.2\/35.1\/38.2-3559","url":"\/38.2-3559\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3559\/","token":"38.2\/35.1\/38.2-3559","dublin_core":{"Title":"Notice of right to external review","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3559","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> A health carrier<\/span> shall notify the covered person<\/span> in writing of an adverse determination or final adverse determination<\/span> and the covered person<\/span>’s right to request an external review. The notice of the right to request an external review shall include the following, or substantially similar, language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals<\/span> who have no association with us if our decision involved making a judgment<\/span> as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Commission<\/span>.” <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The notice of the right to request an external review of an adverse determination shall include the following statements informing the covered person<\/span> that: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> If the covered person<\/span>’s adverse determination involves (i) cancer or (ii) a medical condition where the time frame for completion of an expedited internal appeal<\/span> of an adverse determination would seriously jeopardize the life or health of the covered person<\/span> or would jeopardize the covered person<\/span>’s ability to regain maximum function, the covered person<\/span> or his authorized representative<\/span> may file a request for an expedited external review pursuant to § 38.2-3562<\/a>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> If the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person<\/span>’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person<\/span> or his authorized representative<\/span> may file a request for an expedited external review pursuant to § 38.2-3563<\/a>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> If the covered person<\/span> or his authorized representative<\/span> files a request for an expedited internal appeal<\/span> with the health carrier<\/span>, he may file at the same time a request for an expedited external review of an adverse determination pursuant to § 38.2-3562<\/a> or 38.2-3563<\/a>. The independent review organization<\/span> assigned to conduct the expedited external review will determine whether the covered person<\/span> shall be required to complete the expedited internal appeal<\/span> prior to conducting the expedited external review; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> If the covered person<\/span> or his authorized representative<\/span> files a standard appeal<\/span> with the health carrier<\/span>’s internal appeal<\/span> process, and the health carrier<\/span> does not issue<\/span> a written decision within 30 days following the date the appeal<\/span> requesting a review is filed and the covered person<\/span> or his authorized representative<\/span> did not request or agree to a delay, the covered person<\/span> or his authorized representative<\/span> may file a request for external review and shall be considered to have exhausted the health carrier<\/span>’s internal appeal<\/span> process. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The notice of the right to request an external review of a final adverse determination<\/span> shall include the following statements informing the covered person<\/span> that: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> If the covered person<\/span> has a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or health of the covered person<\/span> or would jeopardize the covered person<\/span>’s ability to regain maximum function, the covered person<\/span> or his authorized representative<\/span> may file a request for an expedited external review pursuant to § 38.2-3562<\/a>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> If the final adverse determination<\/span> involves an admission, availability of care, continued stay<\/span>, or health care service for which the covered person<\/span> received emergency services<\/span>, but has not been discharged from a facility<\/span>, the covered person<\/span> or his authorized representative<\/span> may request an expedited external review pursuant to § 38.2-3562<\/a>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> If the final adverse determination<\/span> involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational, the covered person<\/span> or his authorized representative<\/span> may file a request for a standard external review pursuant to § 38.2-3563<\/a>; or if the covered person<\/span>’s treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person<\/span> or his authorized representative<\/span> may request an expedited external review pursuant to subsection B of § 38.2-3563<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The health carrier<\/span> shall include the standard and expedited external review procedures and any forms with the notice of the right to an external review. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nNOTICE OF RIGHT TO EXTERNAL REVIEW (\u00a7 38.2-3559)\n\nA. A health carrier shall notify the covered person in writing of an adverse\ndetermination or final adverse determination and the covered person’s\nright to request an external review. The notice of the right to request an\nexternal review shall include the following, or substantially similar, language:\n“We have denied your request for the provision of or payment for a health\ncare service or course of treatment. You may have the right to have our decision\nreviewed by health care professionals who have no association with us if our\ndecision involved making a judgment as to the medical necessity,\nappropriateness, health care setting, level of care, or effectiveness of the\nhealth care service or treatment you requested by submitting a request for\nexternal review to the Commission.”\n\nB. The notice of the right to request an external review of an adverse\ndetermination shall include the following statements informing the covered\nperson that:\n\n 1. If the covered person’s adverse determination involves (i) cancer or\n (ii) a medical condition where the time frame for completion of an expedited\n internal appeal of an adverse determination would seriously jeopardize the\n life or health of the covered person or would jeopardize the covered\n person’s ability to regain maximum function, the covered person or his\n authorized representative may file a request for an expedited external review\n pursuant to § 38.2-3562;\n\n 2. If the adverse determination involves a denial of coverage based on a\n determination that the recommended or requested health care service or\n treatment is experimental or investigational and the covered person’s\n treating physician certifies in writing that the recommended or requested\n health care service or treatment would be significantly less effective if not\n promptly initiated, the covered person or his authorized representative may\n file a request for an expedited external review pursuant to § 38.2-3563;\n\n 3. If the covered person or his authorized representative files a request for\n an expedited internal appeal with the health carrier, he may file at the same\n time a request for an expedited external review of an adverse determination\n pursuant to § 38.2-3562 or 38.2-3563. The independent review organization\n assigned to conduct the expedited external review will determine whether the\n covered person shall be required to complete the expedited internal appeal\n prior to conducting the expedited external review; and\n\n 4. If the covered person or his authorized representative files a standard\n appeal with the health carrier’s internal appeal process, and the health\n carrier does not issue a written decision within 30 days following the date\n the appeal requesting a review is filed and the covered person or his\n authorized representative did not request or agree to a delay, the covered\n person or his authorized representative may file a request for external review\n and shall be considered to have exhausted the health carrier’s internal\n appeal process.\n\nC. The notice of the right to request an external review of a final adverse\ndetermination shall include the following statements informing the covered\nperson that:\n\n 1. If the covered person has a medical condition where the time frame for\n completion of a standard external review would seriously jeopardize the life\n or health of the covered person or would jeopardize the covered person’s\n ability to regain maximum function, the covered person or his authorized\n representative may file a request for an expedited external review pursuant to\n § 38.2-3562;\n\n 2. If the final adverse determination involves an admission, availability of\n care, continued stay, or health care service for which the covered person\n received emergency services, but has not been discharged from a facility, the\n covered person or his authorized representative may request an expedited\n external review pursuant to § 38.2-3562; and\n\n 3. If the final adverse determination involves a denial of coverage based on a\n determination that the recommended or requested health care service or\n treatment is experimental or investigational, the covered person or his\n authorized representative may file a request for a standard external review\n pursuant to § 38.2-3563; or if the covered person’s treating\n physician certifies in writing that the recommended or requested health care\n service or treatment would be significantly less effective if not promptly\n initiated, the covered person or his authorized representative may request an\n expedited external review pursuant to subsection B of § 38.2-3563.\n\nD. The health carrier shall include the standard and expedited external review\nprocedures and any forms with the notice of the right to an external review.\n\nHISTORY: 2011, c. 788; 2019, cc. 826, 840.","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}}