                                 CODE OF VIRGINIA

RECONSIDERATION OF ADVERSE DETERMINATION (§ 32.1-137.14)

A. A treating provider may request reconsideration of an adverse determination
pursuant to this section or may appeal an adverse determination pursuant to
&#xA7; 32.1-137.15. Any reconsideration of an adverse determination shall only
be requested by the treating provider on behalf of the covered person. A
determination on reconsideration shall be made by a physician advisor, peer of
the treating health care provider, or a panel of other appropriate health care
providers with at least one physician advisor or peer of the treating health
care provider on the panel.

B. The treating provider on behalf of the covered person shall be (i) notified
verbally at the time of the determination of the reconsideration of the adverse
determination and in writing following the determination of the reconsideration
of the adverse determination, in accordance with &#xA7; 32.1-137.9, including
the criteria used and the clinical reason for the adverse determination and the
alternate length of treatment of the alternate treatment setting or settings, if
any, that the entity deems to be appropriate, and (ii) notified verbally at the
time of the determination of the reconsideration of the adverse determination of
the process for an appeal of the determination pursuant to &#xA7; 32.1-137.15
and the contact name, address, and telephone number to file and perfect an
appeal. If the treating provider on behalf of the covered person requests that
the adverse determination be reviewed by a peer of the treating provider at any
time during the reconsideration process, the request for reconsideration shall
be vacated and considered an appeal pursuant to &#xA7; 32.1-137.15. In such
cases, the covered person shall be notified that the reconsideration has been
vacated and an appeal initiated, all documentation and information provided or
relied upon during the reconsideration process pursuant to this section shall be
converted to the appeal process, and no additional actions shall be required of
the treating provider to perfect the appeal.

C. Any reconsideration shall be rendered and the determination provided to the
treating provider and the covered person in writing within 10 working days of
receipt of the request for reconsideration.

HISTORY: 1998, c. 891; 2010, c. 395; 2011, c. 788.