                                 CODE OF VIRGINIA

DEFINITIONS (§ 32.1-137.7)

As used in this article:
		&#8220;Adverse determination&#8221; means a determination by the managed care
health insurance plan or its designee utilization review entity that, based upon
information provided, a request for a benefit upon application of any
utilization review technique does not meet the managed care health insurance
plan&#8217;s requirements for medical necessity, appropriateness, health care
setting, level of care, or effectiveness or is determined to be experimental or
investigational and the requested benefit is therefore denied, reduced, or
terminated or payment is not provided or made, in whole or in part, for the
benefit. When the policy, contract, plan, certificate, or evidence of coverage
includes coverage for prescription drugs and the health service rendered or
proposed to be rendered is a prescription for the alleviation of cancer pain,
any adverse determination shall be made within 24 hours of the request for
coverage.
		&#8220;Commission&#8221; means the Virginia State Corporation Commission.
		&#8220;Covered person&#8221; means a subscriber, policyholder, member,
enrollee or dependent, as the case may be, under a policy or contract issued or
issued for delivery in Virginia by a managed care health insurance plan
licensee, insurer, health services plan, or preferred provider organization.
		&#8220;Evidence of coverage&#8221; includes any certificate, individual or
group agreement or contract, or identification card or related documents issued
in conjunction with the certificate, agreement or contract, issued to a
subscriber setting out the coverage and other rights to which a covered person
is entitled.
		&#8220;Final adverse determination&#8221; means an adverse determination
involving a covered benefit that has been upheld by a managed care health
insurance plan, or its designee utilization review entity, at the completion of
the managed care health insurance plan&#8217;s internal appeal process.
		&#8220;Medical director&#8221; means a physician licensed to practice medicine
in the Commonwealth of Virginia who is an employee of a utilization review
entity responsible for compliance with the provisions of this article.
		&#8220;Peer of the treating health care provider&#8221; means a physician or
other health care professional who holds a nonrestricted license in the
Commonwealth of Virginia or under a comparable licensing law of a state of the
United States and in the same or similar specialty as typically manages the
medical condition, procedure or treatment under review.
		&#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;Treating health care provider&#8221; or &#8220;provider&#8221; means a
licensed health care provider who renders or proposes to render health care
services to a covered person.
			&#8220;Utilization review&#8221; means a system for reviewing the necessity,
appropriateness and efficiency of hospital, medical or other health care
services 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, managed care health insurance plan
licensee, 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 entity&#8221; or &#8220;entity&#8221; means a
person or entity performing utilization review.
			&#8220;Utilization review plan&#8221; or &#8220;plan&#8221; means a written
procedure for performing review.

HISTORY: 1998, cc. 129, 891; 1999, c. 857; 2000, c. 564; 2011, c. 788.