{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3568.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3568.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3568.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3568.html"}],"law_id":81396,"edition_id":1,"section_id":81396,"structure_id":14588,"section_number":"38.2-3568","catch_line":"External review reporting requirements","history":"2011, c. 788.","full_text":"A\n\nAn independent review organization shall maintain written records, in the aggregate by state and by health carrier, on all external review requests and external reviews conducted during each calendar year. Each independent review organization shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and for each health carrier: the total number of requests for external review; the number of requests for external review resolved and, of those resolved, the number upholding the adverse determination or final adverse determination, and the number reversing the adverse determination or final adverse determination; the average length of time for resolution; a summary of the types of coverages or cases for which an external review was sought; the number of external reviews that were terminated as the result of a reconsideration by the health carrier; and any other information the Commission may request or require. The independent review organization shall retain required written records for at least three years.B\n\nEach health carrier shall maintain written records, in the aggregate by state and for each type of health benefit plan offered, on all requests for external review. Each health carrier shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and by type of health benefit plan: the total number of requests for external review, the number of requests determined eligible for external review, the number of external reviews completed, and any other information the Commission may request or require. The health carrier shall retain required written record for at least three years.","order_by":null,"text":{"0":{"id":291667,"text":"An independent review organization shall maintain written records, in the aggregate by state and by health carrier, on all external review requests and external reviews conducted during each calendar year. Each independent review organization shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and for each health carrier: the total number of requests for external review; the number of requests for external review resolved and, of those resolved, the number upholding the adverse determination or final adverse determination, and the number reversing the adverse determination or final adverse determination; the average length of time for resolution; a summary of the types of coverages or cases for which an external review was sought; the number of external reviews that were terminated as the result of a reconsideration by the health carrier; and any other information the Commission may request or require. The independent review organization shall retain required written records for at least three years.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":291668,"text":"Each health carrier shall maintain written records, in the aggregate by state and for each type of health benefit plan offered, on all requests for external review. Each health carrier shall submit a report to the Commission. The report shall be submitted to the Commission by April 1 of the following calendar year. The report shall include in the aggregate by state, and by type of health benefit plan: the total number of requests for external review, the number of requests determined eligible for external review, the number of external reviews completed, and any other information the Commission may request or require. The health carrier shall retain required written record for at least three years.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3568\/","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":false,"refers_to":false,"permalink":{"id":215987,"object_type":"law","relational_id":81396,"identifier":"38.2-3568","token":"38.2\/35.1\/38.2-3568","url":"\/38.2-3568\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3568\/","token":"38.2\/35.1\/38.2-3568","dublin_core":{"Title":"External review reporting requirements","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3568","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> An independent review organization<\/span> shall maintain written records, in the aggregate by state<\/span> and by health carrier<\/span>, on all external review requests and external reviews conducted during each calendar year. Each independent review organization<\/span> shall submit a report to the Commission<\/span>. The report shall be submitted to the Commission<\/span> by April 1 of the following calendar year. The report shall include in the aggregate by state<\/span>, and for each health carrier<\/span>: the total number of requests for external review; the number of requests for external review resolved and, of those resolved, the number upholding the adverse determination or final adverse determination<\/span>, and the number reversing the adverse determination or final adverse determination<\/span>; the average length of time for resolution; a summary of the types of coverages or cases for which an external review was sought; the number of external reviews that were terminated as the result of a reconsideration by the health carrier<\/span>; and any other information the Commission<\/span> may request or require. The independent review organization<\/span> shall retain required written records for at least three years. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Each health carrier<\/span> shall maintain written records, in the aggregate by state<\/span> and for each type of health benefit plan<\/span> offered, on all requests for external review. Each health carrier<\/span> shall submit a report to the Commission<\/span>. The report shall be submitted to the Commission<\/span> by April 1 of the following calendar year. The report shall include in the aggregate by state<\/span>, and by type of health benefit plan<\/span>: the total number of requests for external review, the number of requests determined eligible for external review, the number of external reviews completed, and any other information the Commission<\/span> may request or require. The health carrier<\/span> shall retain required written record for at least three years. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nEXTERNAL REVIEW REPORTING REQUIREMENTS (\u00a7 38.2-3568)\n\nA. An independent review organization shall maintain written records, in the\naggregate by state and by health carrier, on all external review requests and\nexternal reviews conducted during each calendar year. Each independent review\norganization shall submit a report to the Commission. The report shall be\nsubmitted to the Commission by April 1 of the following calendar year. The\nreport shall include in the aggregate by state, and for each health carrier: the\ntotal number of requests for external review; the number of requests for\nexternal review resolved and, of those resolved, the number upholding the\nadverse determination or final adverse determination, and the number reversing\nthe adverse determination or final adverse determination; the average length of\ntime for resolution; a summary of the types of coverages or cases for which an\nexternal review was sought; the number of external reviews that were terminated\nas the result of a reconsideration by the health carrier; and any other\ninformation the Commission may request or require. The independent review\norganization shall retain required written records for at least three years.\n\nB. Each health carrier shall maintain written records, in the aggregate by state\nand for each type of health benefit plan offered, on all requests for external\nreview. Each health carrier shall submit a report to the Commission. The report\nshall be submitted to the Commission by April 1 of the following calendar year.\nThe report shall include in the aggregate by state, and by type of health\nbenefit plan: the total number of requests for external review, the number of\nrequests determined eligible for external review, the number of external reviews\ncompleted, and any other information the Commission may request or require. The\nhealth carrier shall retain required written record for at least three years.\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}}