                                 CODE OF VIRGINIA

ADVERSE DETERMINATION (§ 32.1-137.13)

A. The treating provider shall be notified in writing of any adverse
determination within two working days of the determination; however, the
treating provider shall be notified orally by telephone within 24 hours of any
adverse determination for a prescription known to be for the alleviation of
cancer pain. Any such notification shall include instructions for the provider
on behalf of the covered person to (i) seek a reconsideration of the adverse
determination pursuant to &#xA7; 32.1-137.14, including the contact name,
address, and telephone number of the person responsible for making the adverse
determination, and (ii) seek an appeal of the adverse determination pursuant to
&#xA7; 32.1-137.15, including the contact name, address, and telephone number to
file and perfect such appeal.

B. No entity shall render an adverse determination unless it has made a good
faith attempt to obtain information from the provider. At any time before the
entity renders its determination, the provider shall be entitled to review the
issue of medical necessity with a physician advisor or peer of the treating
health care provider who represents the entity. For any adverse determination
relating to a prescription to alleviate cancer pain, a physician advisor shall
review the issue of medical necessity with the provider.

HISTORY: 1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.