                                 CODE OF VIRGINIA

UTILIZATION REVIEW PLAN REQUIRED (§ 32.1-137.10)

A. Each utilization review entity subject to this article shall adopt a
utilization review plan that contains procedures for complying with the
requirements and standards of § 32.1-137.9 and other applicable provisions of
this article. Such plan shall contain, at a minimum, the following:

   1. Specific procedures to be used in review determinations, including an
   expedited review of no more than twenty-four hours for review determinations
   relating to prescriptions for the alleviation of cancer pain;

   2. A provision for advance notice to covered persons of any requirements for
   certification of the health care setting or pre-approval of the necessity of
   health care service or any other prerequisites to approval of payment;

   3. A provision for advance notice to covered persons that compliance with the
   review process is not a guarantee of benefits or payment under the health
   benefit plan;

   4. A provision for a process for reconsideration of adverse decisions in
   accordance with &#xA7; 32.1-137.14 and an appeals process in accordance with
   &#xA7; 32.1-137.15; and

   5. Policies and procedures designed to ensure confidentiality of
   patient-specific medical records and information in accordance with subsection
   C of &#xA7; 32.1-137.12.

B. Each utilization review entity subject to this chapter shall make available
to providers and covered persons, upon written request, a copy of those portions
of its utilization review plan relevant to the specific request.

C. The Commissioner shall have the right to determine that an entity has
complied with the requirement that the entity adopt a utilization review plan in
accordance with subsection A.

HISTORY: 1998, c. 891; 1999, c. 857.