{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3560.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3560.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3560.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3560.html"}],"law_id":65207,"edition_id":1,"section_id":65207,"structure_id":14588,"section_number":"38.2-3560","catch_line":"Exhaustion of internal appeal process","history":"2011, c. 788; 2019, cc. 826, 840.","full_text":"A\n\nA request for an external review shall not be made until the covered person has exhausted the health carrier’s internal appeal process, provided that a covered person’s exhaustion of the health carrier’s internal appeal process shall not be required if the adverse determination relates to the treatment of a cancer of the covered person.B\n\nA covered person shall be considered to have exhausted the health carrier’s internal appeal process if the covered person or his authorized representative has filed an appeal requesting a review of an adverse determination, and, except to the extent the covered person or his authorized representative requested or agreed to a delay, has not received a written decision from the health carrier within 30 days following the date the appeal was filed with the health carrier.C\n\nIf a covered person or his authorized representative files a request for an expedited internal appeal of an adverse determination with the health carrier, the covered person or his authorized representative is deemed to have exhausted the internal appeal process and may file a request for an expedited external review of the adverse determination at the same time. Upon receipt of a request for an expedited external review of an adverse determination, the independent review organization conducting the external review shall determine whether the covered person shall be required to complete the health carrier’s expedited internal appeal process before it conducts the expedited external review. The independent review organization shall promptly notify the covered person and his authorized representative, if any, of this determination, and either proceed with the expedited external review or wait until completion of the internal expedited appeal process.D\n\nA request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier’s internal appeal process whenever the health carrier agrees to waive the exhaustion requirement. If the exhaustion requirement is waived, the covered person or his authorized representative may file a request in writing for a standard external review.","order_by":null,"text":{"0":{"id":237144,"text":"A request for an external review shall not be made until the covered person has exhausted the health carrier’s internal appeal process, provided that a covered person’s exhaustion of the health carrier’s internal appeal process shall not be required if the adverse determination relates to the treatment of a cancer of the covered person.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":237145,"text":"A covered person shall be considered to have exhausted the health carrier’s internal appeal process if the covered person or his authorized representative has filed an appeal requesting a review of an adverse determination, and, except to the extent the covered person or his authorized representative requested or agreed to a delay, has not received a written decision from the health carrier within 30 days following the date the appeal was filed with the health carrier.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":237146,"text":"If a covered person or his authorized representative files a request for an expedited internal appeal of an adverse determination with the health carrier, the covered person or his authorized representative is deemed to have exhausted the internal appeal process and may file a request for an expedited external review of the adverse determination at the same time. Upon receipt of a request for an expedited external review of an adverse determination, the independent review organization conducting the external review shall determine whether the covered person shall be required to complete the health carrier’s expedited internal appeal process before it conducts the expedited external review. The independent review organization shall promptly notify the covered person and his authorized representative, if any, of this determination, and either proceed with the expedited external review or wait until completion of the internal expedited appeal process.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":237147,"text":"A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier’s internal appeal process whenever the health carrier agrees to waive the exhaustion requirement. If the exhaustion requirement is waived, the covered person or his authorized representative may file a request in writing for a standard external review.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3560\/","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":false,"permalink":{"id":215955,"object_type":"law","relational_id":65207,"identifier":"38.2-3560","token":"38.2\/35.1\/38.2-3560","url":"\/38.2-3560\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3560\/","token":"38.2\/35.1\/38.2-3560","dublin_core":{"Title":"Exhaustion of internal appeal process","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3560","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> A request for an external review shall not be made until the covered person<\/span> has exhausted the health carrier<\/span>’s internal appeal<\/span> process, provided that a covered person<\/span>’s exhaustion of the health carrier<\/span>’s internal appeal<\/span> process shall not be required if the adverse determination<\/span> relates to the treatment of a cancer of the covered person<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A covered person<\/span> shall be considered to have exhausted the health carrier<\/span>’s internal appeal<\/span> process if the covered person<\/span> or his authorized representative<\/span> has filed an appeal<\/span> requesting a review of an adverse determination<\/span>, and, except to the extent the covered person<\/span> or his authorized representative<\/span> requested or agreed to a delay, has not received a written decision from the health carrier<\/span> within 30 days following the date the appeal<\/span> was filed with the health carrier<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> If a covered person<\/span> or his authorized representative<\/span> files a request for an expedited internal appeal<\/span> of an adverse determination<\/span> with the health carrier<\/span>, the covered person<\/span> or his authorized representative<\/span> is deemed to have exhausted the internal appeal<\/span> process and may file a request for an expedited external review of the adverse determination<\/span> at the same time. Upon receipt of a request for an expedited external review of an adverse determination<\/span>, the independent review organization<\/span> conducting the external review shall determine whether the covered person<\/span> shall be required to complete the health carrier<\/span>’s expedited internal appeal<\/span> process before it conducts the expedited external review. The independent review organization<\/span> shall promptly notify the covered person<\/span> and his authorized representative<\/span>, if any, of this determination, and either proceed with the expedited external review or wait until completion of the internal expedited appeal<\/span> process. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> A request for an external review of an adverse determination<\/span> may be made before the covered person<\/span> has exhausted the health carrier<\/span>’s internal appeal<\/span> process whenever the health carrier<\/span> agrees to waive<\/span> the exhaustion requirement. If the exhaustion requirement is waived, the covered person<\/span> or his authorized representative<\/span> may file a request in writing for a standard external review. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nEXHAUSTION OF INTERNAL APPEAL PROCESS (\u00a7 38.2-3560)\n\nA. A request for an external review shall not be made until the covered person\nhas exhausted the health carrier’s internal appeal process, provided that\na covered person’s exhaustion of the health carrier’s internal\nappeal process shall not be required if the adverse determination relates to the\ntreatment of a cancer of the covered person.\n\nB. A covered person shall be considered to have exhausted the health\ncarrier’s internal appeal process if the covered person or his authorized\nrepresentative has filed an appeal requesting a review of an adverse\ndetermination, and, except to the extent the covered person or his authorized\nrepresentative requested or agreed to a delay, has not received a written\ndecision from the health carrier within 30 days following the date the appeal\nwas filed with the health carrier.\n\nC. If a covered person or his authorized representative files a request for an\nexpedited internal appeal of an adverse determination with the health carrier,\nthe covered person or his authorized representative is deemed to have exhausted\nthe internal appeal process and may file a request for an expedited external\nreview of the adverse determination at the same time. Upon receipt of a request\nfor an expedited external review of an adverse determination, the independent\nreview organization conducting the external review shall determine whether the\ncovered person shall be required to complete the health carrier’s\nexpedited internal appeal process before it conducts the expedited external\nreview. The independent review organization shall promptly notify the covered\nperson and his authorized representative, if any, of this determination, and\neither proceed with the expedited external review or wait until completion of\nthe internal expedited appeal process.\n\nD. A request for an external review of an adverse determination may be made\nbefore the covered person has exhausted the health carrier’s internal\nappeal process whenever the health carrier agrees to waive the exhaustion\nrequirement. If the exhaustion requirement is waived, the covered person or his\nauthorized representative may file a request in writing for a standard external\nreview.\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}}