                                 CODE OF VIRGINIA

DEFINITIONS (§ 38.2-3556)

As used in this chapter, unless the context requires a different meaning:
		&#8220;Adverse determination&#8221; means a determination by a health carrier
or its designee utilization review entity that an admission, availability of
care, continued stay, or other health care service that is a covered benefit has
been reviewed and, based upon the information provided, does not meet the health
carrier&#8217;s requirements for medical necessity, appropriateness, health care
setting, level of care, or effectiveness, and the requested service or payment
for the service is therefore denied, reduced, or terminated.
		&#8220;Ambulatory review&#8221; means utilization review of health care
services performed or provided in an outpatient setting.
		&#8220;Authorized representative&#8221; means (i) a person to whom a covered
person has given express written consent to represent the covered person in an
external review, (ii) a person authorized by law to provide substituted consent
for a covered person, or (iii) a family member of the covered person or the
covered person&#8217;s treating health care professional only when the covered
person is unable to provide consent.
		&#8220;Best evidence&#8221; means evidence based on (i) randomized clinical
trials; if randomized clinical trials are not available, then (ii) cohort
studies or case-control studies; if clauses (i) and (ii) are not available, then
(iii) case-series; or if clauses (i), (ii), and (iii) are not available, then
(iv) expert opinion.
		&#8220;Case-control study&#8221; means a retrospective evaluation of two
groups of patients with different outcomes to determine which specific
interventions the patients received.
		&#8220;Case management&#8221; means a coordinated set of activities conducted
for individual patient management of serious, complicated, protracted, or other
health conditions.
		&#8220;Case-series&#8221; means an evaluation of a series of patients with a
particular outcome, without the use of a control group.
		&#8220;Certification&#8221; means a determination by a health carrier or its
designee utilization review entity that an admission, availability of care,
continued stay, or other health care service has been reviewed and, based on the
information provided, satisfies the health carrier&#8217;s requirements for
medical necessity, appropriateness, health care setting, level of care, and
effectiveness.
		&#8220;Clinical review criteria&#8221; means the written screening procedures,
decision abstracts, clinical protocols, and practice guidelines used by a health
carrier to determine the necessity and appropriateness of health care services.
		&#8220;Cohort study&#8221; means a prospective evaluation of two groups of
patients with only one group of patients receiving a specific intervention.
		&#8220;Concurrent review&#8221; means utilization review conducted during a
patient&#8217;s hospital stay or course of treatment.
		&#8220;Covered benefits&#8221; or &#8220;benefits&#8221; means those health
care services to which a covered person is entitled under the terms of a health
benefit plan.
		&#8220;Covered person&#8221; means a policyholder, subscriber, enrollee, or
other individual participating in a health benefit plan.
		&#8220;Discharge planning&#8221; means the formal process for determining,
prior to discharge from a facility, the coordination and management of the care
that a patient receives following discharge from a facility.
		&#8220;Emergency medical condition&#8221; means the sudden and, at the time,
unexpected onset of a health condition or illness that requires immediate
medical attention, where failure to provide medical attention would result in a
serious impairment to bodily functions or a serious dysfunction of a bodily
organ or part, or would place the person&#8217;s health in serious jeopardy.
		&#8220;Emergency services&#8221; means health care items and services
furnished or required to evaluate and treat an emergency medical condition.
		&#8220;Evidence-based standard&#8221; means the conscientious, explicit, and
judicious use of the current best evidence based on the overall systematic
review of the research in making decisions about the care of individual
patients.
		&#8220;Expert opinion&#8221; means a belief or an interpretation by
specialists with experience in a specific area about the scientific evidence
pertaining to a particular service, intervention, or therapy.
		&#8220;Facility&#8221; means an institution providing health care services or
a health care setting, including hospitals and other licensed inpatient centers;
ambulatory surgical or treatment centers; skilled nursing centers; residential
treatment centers; diagnostic, laboratory, and imaging centers; and
rehabilitation and other therapeutic health settings.
		&#8220;Final adverse determination&#8221; means an adverse determination
involving a covered benefit that has been upheld by a health carrier, or its
designee utilization review entity, at the completion of the health
carrier&#8217;s internal appeal process.
		&#8220;Health benefit plan&#8221; means a policy, contract, certificate, or
agreement offered or issued by a health carrier to provide, deliver, arrange
for, pay for, or reimburse any of the costs of health care services.
		&#8220;Health care professional&#8221; means a physician or other health care
practitioner licensed, accredited, or certified to perform specified health care
services consistent with the laws of the Commonwealth.
		&#8220;Health care provider&#8221; or &#8220;provider&#8221; means a health
care professional or a facility.
		&#8220;Health care services&#8221; means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition, illness, injury,
or disease.
		&#8220;Health carrier&#8221; means an entity, subject to the insurance laws
and regulations of the Commonwealth or subject to the jurisdiction of the
Commission, that contracts or offers to contract to provide, deliver, arrange
for, pay for, or reimburse any of the costs of health care services, including
an accident and sickness insurance company, a health maintenance organization, a
nonprofit hospital and health service corporation, or a nonstock corporation
offering or administering a health services plan, a hospital services plan, or a
medical or surgical services plan, or any other entity providing a plan of
health insurance, health benefits, or health care services except as excluded
under § 38.2-3557.
		&#8220;Independent review organization&#8221; means an entity that conducts
independent external reviews of adverse determinations and final adverse
determinations.
		&#8220;Medical or scientific evidence&#8221; means evidence found in (i)
peer-reviewed scientific studies published in or accepted for publication by
medical journals that meet nationally recognized requirements for scientific
manuscripts and that submit most of their published articles for review by
experts who are not part of the editorial staff; (ii) peer-reviewed medical
literature, including literature relating to therapies reviewed and approved by
a qualified institutional review board, biomedical compendia, and other medical
literature that meet the criteria of the National Institutes of Health&#8217;s
Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science
Ltd. for indexing in Excerpta Medica (EMBASE); (iii) medical journals recognized
by the Secretary of Health and Human Services under § 1861(t)(2) of the federal
Social Security Act; (iv) the following standard reference compendia: the
American Hospital Formulary Service Drug Information; Drug Facts and
Comparisons; the American Dental Association Accepted Dental Therapeutics; the
United States Pharmacopeia &#8212; Drug Information; National Comprehensive
Cancer Network&#8217;s Drugs &#038; Biologics Compendium; and Elsevier Gold
Standard&#8217;s Clinical Pharmacology; (v) findings, studies, or research
conducted by or under the auspices of federal government agencies and nationally
recognized federal research institutes, including the federal Agency for
Healthcare Research and Quality, the National Institutes of Health, the National
Cancer Institute, the National Academy of Sciences, the Centers for Medicare and
Medicaid Services, the federal Food and Drug Administration, and any national
board recognized by the National Institutes of Health for the purpose of
evaluating the medical value of health care services; or (vi) any other medical
or scientific evidence that is comparable to the sources listed in clauses (i)
through (v).
		&#8220;NAIC&#8221; means the National Association of Insurance Commissioners.
		&#8220;Prospective review&#8221; means utilization review conducted prior to
an admission or a course of treatment.
		&#8220;Randomized clinical trial&#8221; means a controlled, prospective study
of patients that have been randomized into an experimental group and a control
group at the beginning of the study with only the experimental group of patients
receiving a specific intervention and includes study of the groups for variables
and anticipated outcomes over time.
		&#8220;Retrospective review&#8221; means a review of medical necessity
conducted after services have been provided to a patient, but does not include
the review of a claim that is limited to an evaluation of reimbursement levels,
veracity of documentation, accuracy of coding, or adjudication for payment.
		&#8220;Second opinion&#8221; means an opportunity or requirement to obtain a
clinical evaluation by a provider other than the one originally making a
recommendation for a proposed health care service to assess the clinical
necessity and appropriateness of the initial proposed health care service.
		&#8220;Utilization review&#8221; means a set of formal techniques designed to
monitor the use of, or evaluate the clinical necessity, appropriateness,
efficacy, or efficiency of, health care services, procedures, or settings.
Techniques may include ambulatory review, prospective review, second opinion,
certification, concurrent review, case management, discharge planning, or
retrospective review.
		&#8220;Utilization review entity&#8221; means an individual or entity that
conducts utilization review.

HISTORY: 2011, c. 788.