                                 CODE OF VIRGINIA

DEFINITIONS (§ 32.1-138.6)

In this chapter the following terms have the meanings indicated:
		&#8220;Certificate of registration&#8221; means a certificate of registration
granted by the Department of Health to a private review agent.
		&#8220;Medical director&#8221; means a physician licensed to practice medicine
in the Commonwealth of Virginia who is an employee of a utilization review
organization responsible for compliance with the provisions of this article.
		&#8220;Physician advisor&#8221; means a physician licensed to practice
medicine in the Commonwealth of Virginia or under a comparable licensing law of
a state of the United States who provides medical advice or information to a
private review agent or a utilization review entity in connection with its
utilization review activities.
		&#8220;Private review agent&#8221; means a person or entity performing
utilization reviews, except that the term shall not include the following
entities or employees of any such entity so long as they conduct utilization
reviews solely for subscribers, policyholders, members or enrollees:

1. A health maintenance organization authorized to transact business in
Virginia; or

2. A health insurer, hospital service corporation, health services plan or
preferred provider organization authorized to offer health benefits in this
Commonwealth.
			&#8220;Utilization review&#8221; means a system for reviewing the necessity,
appropriateness and efficiency of hospital, medical or other health care
resources rendered or proposed to be rendered to a patient or group of patients
for the purpose of determining whether such services should be covered or
provided by an insurer, health services plan, health maintenance organization,
or other entity or person. For purposes of this article, &#8220;utilization
review&#8221; shall include, but not be limited to, preadmission, concurrent and
retrospective medical necessity determination, and review related to the
appropriateness of the site at which services were or are to be delivered.
&#8220;Utilization review&#8221; shall not include (i) any review of issues
concerning insurance contract coverage or contractual restrictions on facilities
to be used for the provision of services, (ii) any review of patient information
by an employee of or consultant to any licensed hospital for patients of such
hospital, or (iii) any determination by an insurer as to the reasonableness and
necessity of services for the treatment and care of an injury suffered by an
insured for which reimbursement is claimed under a contract of insurance
covering any classes of insurance defined in &#xA7;&#xA7; 38.2-117, 38.2-118,
38.2-119, 38.2-124, 38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132 and
38.2-134.
			&#8220;Utilization review program&#8221; means a program for conducting
utilization reviews by a private review agent.

HISTORY: 1990, c. 826, § 38.2-5300; 1995, c. 745; 1996, c. 259; 1998, c. 129;
2000, c. 564.