{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3561.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3561.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3561.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3561.html"}],"law_id":66856,"edition_id":1,"section_id":66856,"structure_id":14588,"section_number":"38.2-3561","catch_line":"Standard external review","history":"2011, c. 788; 2019, cc. 826, 840.","full_text":"A\n\nWithin 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination or an adverse determination if the internal appeal process has been deemed to be exhausted or waived, a covered person or his authorized representative may file a request for an external review in writing with the Commission. Within one business day after the date of receipt of a request for external review, the Commission shall send a copy of the request to the health carrier.B\n\nWithin five business days following the date of receipt of the external review request from the Commission, the health carrier shall complete a preliminary review of the request to determine whether:1\n\nThe individual is or was a covered person at the time the health care service was requested or, in the case of a retrospective review, was a covered person at the time the health care service was provided;2\n\nThe health care service is a covered service, except as excluded for not meeting the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;3\n\nThe covered person has exhausted or is deemed to have 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; and4\n\nAll the information and forms required to process the external review are complete.C\n\nWithin one business day after completion of the preliminary review, the health carrier shall notify in writing the Commission, the covered person, and his authorized representative, if any, whether the request is complete and eligible for external review and, if ineligible, the reasons for ineligibility. If the request is not complete, the notice shall include what information or materials are needed to make the request complete. Such notice shall include a statement informing the covered person and his authorized representative, if any, that the health carrier’s determination of ineligibility may be appealed to the Commission. If the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection B.D\n\nWithin one business day after the date of receipt of the notice described in subsection C, the Commission shall assign an independent review organization to conduct the external review and notify in writing the health carrier, the covered person, and his authorized representative, if any, of the request’s eligibility and acceptance for external review and the name of the assigned independent review organization. The Commission shall include in such notice a statement that the covered person or his authorized representative may submit in writing to the assigned independent review organization, within five business days following the date of receipt, additional information that the independent review organization shall consider when conducting the external review.E\n\nWithin five business days after the date of receipt of the notice from the Commission, the health carrier or its designee utilization review entity shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination. Failure by the health carrier or its utilization review entity to provide the documents and information within the time specified shall not delay the conduct of the external review. If the health carrier or its utilization review entity fails to provide the documents and information within the time specified, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. Within one business day after making such decision, the independent review organization shall notify the covered person, his authorized representative, if any, the health carrier, and the Commission.F\n\nThe assigned independent review organization shall review all of the information and documents timely received from the health carrier and any other information submitted in writing by the covered person or his authorized representative. The independent review organization is not required to, but may, accept and consider information submitted late from the covered person or his authorized representative, if any. Upon receipt of any information submitted by the covered person or his authorized representative, the assigned independent review organization shall within one business day forward the information to the health carrier.G\n\nUpon receipt of the information from the assigned independent review organization, the health carrier may reconsider its adverse determination or final adverse determination. Reconsideration by the health carrier of its adverse determination or final adverse determination shall not delay or terminate the external review. The external review may only be terminated if the health carrier decides to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service. Within one business day after making the decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the covered person, his authorized representative, if any, the assigned independent review organization, and the Commission in writing of its decision. Upon receipt of the notice of the health carrier’s decision to reverse its adverse determination or final adverse determination, the assigned independent review organization shall terminate the external review.H\n\nThe assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall also consider the following in reaching a decision:1\n\nThe covered person’s medical records;2\n\nThe attending health care professional’s recommendation;3\n\nConsulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, his authorized representative, or the covered person’s treating provider;4\n\nThe terms of coverage under the covered person’s health benefit plan;5\n\nThe most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations;6\n\nAny applicable clinical review criteria developed and used by the health carrier or its designee utilization review entity; and7\n\nThe opinion of the independent review organization’s clinical reviewer or reviewers after considering the information or documents described in subdivisions 1 through 6 to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.\n\t\t\t\tIn reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier’s utilization review process or the internal appeal process.I\n\nWithin 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person, his authorized representative, if any, the health carrier, and the Commission. The independent review organization shall include in such notice: a general description of the reason for the request for external review; the date the independent review organization received the assignment from the Commission to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision; the rationale for its decision; and references to the evidence or documentation, including evidence-based standards, considered in reaching its decision.J\n\nUpon receipt of a notice reversing the adverse determination or final adverse determination, the health carrier promptly shall approve the coverage.","order_by":null,"text":{"0":{"id":242408,"text":"Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination or an adverse determination if the internal appeal process has been deemed to be exhausted or waived, a covered person or his authorized representative may file a request for an external review in writing with the Commission. Within one business day after the date of receipt of a request for external review, the Commission shall send a copy of the request to the health carrier.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":242409,"text":"Within five business days following the date of receipt of the external review request from the Commission, the health carrier shall complete a preliminary review of the request to determine whether:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":242410,"text":"The individual is or was a covered person at the time the health care service was requested or, in the case of a retrospective review, was a covered person at the time the health care service was provided;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":242411,"text":"The health care service is a covered service, except as excluded for not meeting the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":242412,"text":"The covered person has exhausted or is deemed to have 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; and","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":242413,"text":"All the information and forms required to process the external review are complete.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"C"},"6":{"id":242414,"text":"Within one business day after completion of the preliminary review, the health carrier shall notify in writing the Commission, the covered person, and his authorized representative, if any, whether the request is complete and eligible for external review and, if ineligible, the reasons for ineligibility. If the request is not complete, the notice shall include what information or materials are needed to make the request complete. Such notice shall include a statement informing the covered person and his authorized representative, if any, that the health carrier’s determination of ineligibility may be appealed to the Commission. If the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection B.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B4","next_prefix":"D"},"7":{"id":242415,"text":"Within one business day after the date of receipt of the notice described in subsection C, the Commission shall assign an independent review organization to conduct the external review and notify in writing the health carrier, the covered person, and his authorized representative, if any, of the request’s eligibility and acceptance for external review and the name of the assigned independent review organization. The Commission shall include in such notice a statement that the covered person or his authorized representative may submit in writing to the assigned independent review organization, within five business days following the date of receipt, additional information that the independent review organization shall consider when conducting the external review.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"8":{"id":242416,"text":"Within five business days after the date of receipt of the notice from the Commission, the health carrier or its designee utilization review entity shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination. Failure by the health carrier or its utilization review entity to provide the documents and information within the time specified shall not delay the conduct of the external review. If the health carrier or its utilization review entity fails to provide the documents and information within the time specified, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. Within one business day after making such decision, the independent review organization shall notify the covered person, his authorized representative, if any, the health carrier, and the Commission.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"9":{"id":242417,"text":"The assigned independent review organization shall review all of the information and documents timely received from the health carrier and any other information submitted in writing by the covered person or his authorized representative. The independent review organization is not required to, but may, accept and consider information submitted late from the covered person or his authorized representative, if any. Upon receipt of any information submitted by the covered person or his authorized representative, the assigned independent review organization shall within one business day forward the information to the health carrier.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"10":{"id":242418,"text":"Upon receipt of the information from the assigned independent review organization, the health carrier may reconsider its adverse determination or final adverse determination. Reconsideration by the health carrier of its adverse determination or final adverse determination shall not delay or terminate the external review. The external review may only be terminated if the health carrier decides to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service. Within one business day after making the decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the covered person, his authorized representative, if any, the assigned independent review organization, and the Commission in writing of its decision. Upon receipt of the notice of the health carrier’s decision to reverse its adverse determination or final adverse determination, the assigned independent review organization shall terminate the external review.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"11":{"id":242419,"text":"The assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall also consider the following in reaching a decision:","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"H1"},"12":{"id":242420,"text":"The covered person’s medical records;","type":"section","prefixes":["H","1"],"prefix":"1","entire_prefix":"H1","prefix_anchor":"H1","level":2,"prior_prefix":"H","next_prefix":"H2"},"13":{"id":242421,"text":"The attending health care professional’s recommendation;","type":"section","prefixes":["H","2"],"prefix":"2","entire_prefix":"H2","prefix_anchor":"H2","level":2,"prior_prefix":"H1","next_prefix":"H3"},"14":{"id":242422,"text":"Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, his authorized representative, or the covered person’s treating provider;","type":"section","prefixes":["H","3"],"prefix":"3","entire_prefix":"H3","prefix_anchor":"H3","level":2,"prior_prefix":"H2","next_prefix":"H4"},"15":{"id":242423,"text":"The terms of coverage under the covered person’s health benefit plan;","type":"section","prefixes":["H","4"],"prefix":"4","entire_prefix":"H4","prefix_anchor":"H4","level":2,"prior_prefix":"H3","next_prefix":"H5"},"16":{"id":242424,"text":"The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations;","type":"section","prefixes":["H","5"],"prefix":"5","entire_prefix":"H5","prefix_anchor":"H5","level":2,"prior_prefix":"H4","next_prefix":"H6"},"17":{"id":242425,"text":"Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review entity; and","type":"section","prefixes":["H","6"],"prefix":"6","entire_prefix":"H6","prefix_anchor":"H6","level":2,"prior_prefix":"H5","next_prefix":"H7"},"18":{"id":242426,"text":"The opinion of the independent review organization’s clinical reviewer or reviewers after considering the information or documents described in subdivisions 1 through 6 to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.\n\t\t\t\tIn reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier’s utilization review process or the internal appeal process.","type":"section","prefixes":["H","7"],"prefix":"7","entire_prefix":"H7","prefix_anchor":"H7","level":2,"prior_prefix":"H6","next_prefix":"I"},"19":{"id":242427,"text":"Within 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person, his authorized representative, if any, the health carrier, and the Commission. The independent review organization shall include in such notice: a general description of the reason for the request for external review; the date the independent review organization received the assignment from the Commission to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision; the rationale for its decision; and references to the evidence or documentation, including evidence-based standards, considered in reaching its decision.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H7","next_prefix":"J"},"20":{"id":242428,"text":"Upon receipt of a notice reversing the adverse determination or final adverse determination, the health carrier promptly shall approve the coverage.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3561\/","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":[{"id":83961,"section_number":"38.2-3562","catch_line":"Expedited external review","order_by":null,"url":"\/38.2-3562\/"}],"refers_to":false,"permalink":{"id":215959,"object_type":"law","relational_id":66856,"identifier":"38.2-3561","token":"38.2\/35.1\/38.2-3561","url":"\/38.2-3561\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3561\/","token":"38.2\/35.1\/38.2-3561","dublin_core":{"Title":"Standard external review","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3561","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination<\/span> or an adverse determination if the internal appeal<\/span> process has been deemed to be exhausted or waived, a covered person<\/span> or his authorized representative<\/span> may file a request for an external review in writing with the Commission<\/span>. Within one business day after the date of receipt of a request for external review, the Commission<\/span> shall send a copy of the request to the health carrier<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Within five business days following the date of receipt of the external review request from the Commission<\/span>, the health carrier<\/span> shall complete a preliminary review of the request to determine whether: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The individual is or was a covered person<\/span> at the time the health care service was requested or, in the case of a retrospective review<\/span>, was a covered person<\/span> at the time the health care service was provided; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The health care service is a covered service, except as excluded for not meeting the health carrier<\/span>’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The covered person<\/span> has exhausted or is deemed to have 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 relates to the treatment of a cancer of the covered person<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> All the information and forms required to process the external review are complete. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Within one business day after completion of the preliminary review, the health carrier<\/span> shall notify in writing the Commission<\/span>, the covered person<\/span>, and his authorized representative<\/span>, if any, whether the request is complete and eligible for external review and, if ineligible, the reasons for ineligibility. If the request is not complete, the notice shall include what information or materials<\/span> are needed to make the request complete. Such notice shall include a statement informing the covered person<\/span> and his authorized representative<\/span>, if any, that the health carrier<\/span>’s determination of ineligibility may be appealed to the Commission<\/span>. If the health carrier<\/span> makes an ineligibility determination, the Commission<\/span> may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission<\/span>’s decision shall be made in accordance with the terms of the covered person<\/span>’s health benefit plan<\/span> and the requirements of subsection B. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Within one business day after the date of receipt of the notice described in subsection C, the Commission<\/span> shall assign an independent review organization<\/span> to conduct the external review and notify in writing the health carrier<\/span>, the covered person<\/span>, and his authorized representative<\/span>, if any, of the request’s eligibility and acceptance for external review and the name of the assigned independent review organization<\/span>. The Commission<\/span> shall include in such notice a statement that the covered person<\/span> or his authorized representative<\/span> may submit in writing to the assigned independent review organization<\/span>, within five business days following the date of receipt, additional information that the independent review organization<\/span> shall consider when conducting the external review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Within five business days after the date of receipt of the notice from the Commission<\/span>, the health carrier<\/span> or its designee utilization review entity<\/span> shall provide to the assigned independent review organization<\/span> the documents and any information considered in making the adverse determination or final adverse determination<\/span>. Failure by the health carrier<\/span> or its utilization review entity<\/span> to provide the documents and information within the time specified shall not delay the conduct of the external review. If the health carrier<\/span> or its utilization review entity<\/span> fails to provide the documents and information within the time specified, the assigned independent review organization<\/span> may terminate the external review and make a decision to reverse<\/span> the adverse determination or final adverse determination<\/span>. Within one business day after making such decision, the independent review organization<\/span> shall notify the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The assigned independent review organization<\/span> shall review all of the information and documents timely received from the health carrier<\/span> and any other information submitted in writing by the covered person<\/span> or his authorized representative<\/span>. The independent review organization<\/span> is not required to, but may, accept and consider information submitted late from the covered person<\/span> or his authorized representative<\/span>, if any. Upon receipt of any information submitted by the covered person<\/span> or his authorized representative<\/span>, the assigned independent review organization<\/span> shall within one business day forward the information to the health carrier<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> Upon receipt of the information from the assigned independent review organization<\/span>, the health carrier<\/span> may reconsider its adverse determination or final adverse determination<\/span>. Reconsideration by the health carrier<\/span> of its adverse determination or final adverse determination<\/span> shall not delay or terminate the external review. The external review may only be terminated if the health carrier<\/span> decides to reverse<\/span> its adverse determination or final adverse determination<\/span> and provide coverage or payment for the health care service. Within one business day after making the decision to reverse<\/span> its adverse determination or final adverse determination<\/span>, the health carrier<\/span> shall notify the covered person<\/span>, his authorized representative<\/span>, if any, the assigned independent review organization<\/span>, and the Commission<\/span> in writing of its decision. Upon receipt of the notice of the health carrier<\/span>’s decision to reverse<\/span> its adverse determination or final adverse determination<\/span>, the assigned independent review organization<\/span> shall terminate the external review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> The assigned independent review organization<\/span>, to the extent the information or documents are available and the independent review organization<\/span> considers them appropriate, shall also consider the following in reaching a decision: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The covered person<\/span>’s medical records; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The attending health care professional<\/span>’s recommendation; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Consulting reports from appropriate health care professionals<\/span> and other documents submitted by the health carrier<\/span>, covered person<\/span>, his authorized representative<\/span>, or the covered person<\/span>’s treating provider<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> The terms of coverage under the covered person<\/span>’s health benefit plan<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> The most appropriate practice guidelines, which shall include applicable evidence<\/span>-based standards<\/span> and may include any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Any applicable clinical review criteria<\/span> developed and used by the health carrier<\/span> or its designee utilization review entity<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> The opinion<\/span> of the independent review organization<\/span>’s clinical reviewer or reviewers after considering the information or documents described in subdivisions 1 through 6 to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.\n\t\t\t\tIn reaching a decision, the assigned independent review organization<\/span> shall not be bound by any decisions or conclusions reached during the health carrier<\/span>’s utilization review process or the internal appeal<\/span> process. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> Within 45 days after the date of receipt of the request for an external review, the assigned independent review organization<\/span> shall provide written notice of its decision to uphold<\/span> or reverse<\/span> the adverse determination or the final adverse determination<\/span> to the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. The independent review organization<\/span> shall include in such notice: a general description of the reason for the request for external review; the date the independent review organization<\/span> received the assignment from the Commission<\/span> to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision, including what applicable, if any, evidence<\/span>-based standards<\/span> were a basis for its decision; the rationale for its decision; and references to the evidence<\/span> or documentation, including evidence<\/span>-based standards<\/span>, considered in reaching its decision. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> Upon receipt of a notice reversing the adverse determination or final adverse determination<\/span>, the health carrier<\/span> promptly shall approve the coverage. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nSTANDARD EXTERNAL REVIEW (\u00a7 38.2-3561)\n\nA. Within 120 days after the date of receipt of a notice of the right to an\nexternal review of a final adverse determination or an adverse determination if\nthe internal appeal process has been deemed to be exhausted or waived, a covered\nperson or his authorized representative may file a request for an external\nreview in writing with the Commission. Within one business day after the date of\nreceipt of a request for external review, the Commission shall send a copy of\nthe request to the health carrier.\n\nB. Within five business days following the date of receipt of the external\nreview request from the Commission, the health carrier shall complete a\npreliminary review of the request to determine whether:\n\n 1. The individual is or was a covered person at the time the health care\n service was requested or, in the case of a retrospective review, was a covered\n person at the time the health care service was provided;\n\n 2. The health care service is a covered service, except as excluded for not\n meeting the health carrier’s requirements for medical necessity,\n appropriateness, health care setting, level of care, or effectiveness;\n\n 3. The covered person has exhausted or is deemed to have exhausted the health\n carrier’s internal appeal process, provided that a covered\n person’s exhaustion of the health carrier’s internal appeal\n process shall not be required if the adverse determination relates to the\n treatment of a cancer of the covered person; and\n\n 4. All the information and forms required to process the external review are\n complete.\n\nC. Within one business day after completion of the preliminary review, the\nhealth carrier shall notify in writing the Commission, the covered person, and\nhis authorized representative, if any, whether the request is complete and\neligible for external review and, if ineligible, the reasons for ineligibility.\nIf the request is not complete, the notice shall include what information or\nmaterials are needed to make the request complete. Such notice shall include a\nstatement informing the covered person and his authorized representative, if\nany, that the health carrier’s determination of ineligibility may be\nappealed to the Commission. If the health carrier makes an ineligibility\ndetermination, the Commission may determine that a request is eligible for\nexternal review and require that it be referred for external review. In making\nthis determination, the Commission’s decision shall be made in accordance\nwith the terms of the covered person’s health benefit plan and the\nrequirements of subsection B.\n\nD. Within one business day after the date of receipt of the notice described in\nsubsection C, the Commission shall assign an independent review organization to\nconduct the external review and notify in writing the health carrier, the\ncovered person, and his authorized representative, if any, of the\nrequest’s eligibility and acceptance for external review and the name of\nthe assigned independent review organization. The Commission shall include in\nsuch notice a statement that the covered person or his authorized representative\nmay submit in writing to the assigned independent review organization, within\nfive business days following the date of receipt, additional information that\nthe independent review organization shall consider when conducting the external\nreview.\n\nE. Within five business days after the date of receipt of the notice from the\nCommission, the health carrier or its designee utilization review entity shall\nprovide to the assigned independent review organization the documents and any\ninformation considered in making the adverse determination or final adverse\ndetermination. Failure by the health carrier or its utilization review entity to\nprovide the documents and information within the time specified shall not delay\nthe conduct of the external review. If the health carrier or its utilization\nreview entity fails to provide the documents and information within the time\nspecified, the assigned independent review organization may terminate the\nexternal review and make a decision to reverse the adverse determination or\nfinal adverse determination. Within one business day after making such decision,\nthe independent review organization shall notify the covered person, his\nauthorized representative, if any, the health carrier, and the Commission.\n\nF. The assigned independent review organization shall review all of the\ninformation and documents timely received from the health carrier and any other\ninformation submitted in writing by the covered person or his authorized\nrepresentative. The independent review organization is not required to, but may,\naccept and consider information submitted late from the covered person or his\nauthorized representative, if any. Upon receipt of any information submitted by\nthe covered person or his authorized representative, the assigned independent\nreview organization shall within one business day forward the information to the\nhealth carrier.\n\nG. Upon receipt of the information from the assigned independent review\norganization, the health carrier may reconsider its adverse determination or\nfinal adverse determination. Reconsideration by the health carrier of its\nadverse determination or final adverse determination shall not delay or\nterminate the external review. The external review may only be terminated if the\nhealth carrier decides to reverse its adverse determination or final adverse\ndetermination and provide coverage or payment for the health care service.\nWithin one business day after making the decision to reverse its adverse\ndetermination or final adverse determination, the health carrier shall notify\nthe covered person, his authorized representative, if any, the assigned\nindependent review organization, and the Commission in writing of its decision.\nUpon receipt of the notice of the health carrier’s decision to reverse its\nadverse determination or final adverse determination, the assigned independent\nreview organization shall terminate the external review.\n\nH. The assigned independent review organization, to the extent the information\nor documents are available and the independent review organization considers\nthem appropriate, shall also consider the following in reaching a decision:\n\n 1. The covered person’s medical records;\n\n 2. The attending health care professional’s recommendation;\n\n 3. Consulting reports from appropriate health care professionals and other\n documents submitted by the health carrier, covered person, his authorized\n representative, or the covered person’s treating provider;\n\n 4. The terms of coverage under the covered person’s health benefit plan;\n\n 5. The most appropriate practice guidelines, which shall include applicable\n evidence-based standards and may include any other practice guidelines\n developed by the federal government or national or professional medical\n societies, boards, and associations;\n\n 6. Any applicable clinical review criteria developed and used by the health\n carrier or its designee utilization review entity; and\n\n 7. The opinion of the independent review organization’s clinical\n reviewer or reviewers after considering the information or documents described\n in subdivisions 1 through 6 to the extent the information or documents are\n available and the clinical reviewer or reviewers consider appropriate.\n \t\t\t\tIn reaching a decision, the assigned independent review organization shall\n not be bound by any decisions or conclusions reached during the health\n carrier’s utilization review process or the internal appeal process.\n\nI. Within 45 days after the date of receipt of the request for an external\nreview, the assigned independent review organization shall provide written\nnotice of its decision to uphold or reverse the adverse determination or the\nfinal adverse determination to the covered person, his authorized\nrepresentative, if any, the health carrier, and the Commission. The independent\nreview organization shall include in such notice: a general description of the\nreason for the request for external review; the date the independent review\norganization received the assignment from the Commission to conduct the external\nreview; the date the external review was conducted; the date of its decision;\nthe principal reason or reasons for its decision, including what applicable, if\nany, evidence-based standards were a basis for its decision; the rationale for\nits decision; and references to the evidence or documentation, including\nevidence-based standards, considered in reaching its decision.\n\nJ. Upon receipt of a notice reversing the adverse determination or final adverse\ndetermination, the health carrier promptly shall approve the coverage.\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}}