                                 CODE OF VIRGINIA

STANDARD EXTERNAL REVIEW (§ 38.2-3561)

A. Within 120 days after the date of receipt of a notice of the right to an
external review of a final adverse determination or an adverse determination if
the internal appeal process has been deemed to be exhausted or waived, a covered
person or his authorized representative may file a request for an external
review in writing with the Commission. Within one business day after the date of
receipt of a request for external review, the Commission shall send a copy of
the request to the health carrier.

B. Within five business days following the date of receipt of the external
review request from the Commission, the health carrier shall complete a
preliminary review of the request to determine whether:

   1. The individual is or was a covered person at the time the health care
   service was requested or, in the case of a retrospective review, was a covered
   person at the time the health care service was provided;

   2. The health care service is a covered service, except as excluded for not
   meeting the health carrier&#8217;s requirements for medical necessity,
   appropriateness, health care setting, level of care, or effectiveness;

   3. The covered person has exhausted or is deemed to have exhausted the health
   carrier&#8217;s internal appeal process, provided that a covered
   person&#8217;s exhaustion of the health carrier&#8217;s internal appeal
   process shall not be required if the adverse determination relates to the
   treatment of a cancer of the covered person; and

   4. All the information and forms required to process the external review are
   complete.

C. Within one business day after completion of the preliminary review, the
health carrier shall notify in writing the Commission, the covered person, and
his authorized representative, if any, whether the request is complete and
eligible for external review and, if ineligible, the reasons for ineligibility.
If the request is not complete, the notice shall include what information or
materials are needed to make the request complete. Such notice shall include a
statement informing the covered person and his authorized representative, if
any, that the health carrier&#8217;s determination of ineligibility may be
appealed to the Commission. If the health carrier makes an ineligibility
determination, the Commission may determine that a request is eligible for
external review and require that it be referred for external review. In making
this determination, the Commission&#8217;s decision shall be made in accordance
with the terms of the covered person&#8217;s health benefit plan and the
requirements of subsection B.

D. Within one business day after the date of receipt of the notice described in
subsection C, the Commission shall assign an independent review organization to
conduct the external review and notify in writing the health carrier, the
covered person, and his authorized representative, if any, of the
request&#8217;s eligibility and acceptance for external review and the name of
the assigned independent review organization. The Commission shall include in
such notice a statement that the covered person or his authorized representative
may submit in writing to the assigned independent review organization, within
five business days following the date of receipt, additional information that
the independent review organization shall consider when conducting the external
review.

E. Within five business days after the date of receipt of the notice from the
Commission, the health carrier or its designee utilization review entity shall
provide to the assigned independent review organization the documents and any
information considered in making the adverse determination or final adverse
determination. Failure by the health carrier or its utilization review entity to
provide the documents and information within the time specified shall not delay
the conduct of the external review. If the health carrier or its utilization
review entity fails to provide the documents and information within the time
specified, the assigned independent review organization may terminate the
external review and make a decision to reverse the adverse determination or
final adverse determination. Within one business day after making such decision,
the independent review organization shall notify the covered person, his
authorized representative, if any, the health carrier, and the Commission.

F. The assigned independent review organization shall review all of the
information and documents timely received from the health carrier and any other
information submitted in writing by the covered person or his authorized
representative. The independent review organization is not required to, but may,
accept and consider information submitted late from the covered person or his
authorized representative, if any. Upon receipt of any information submitted by
the covered person or his authorized representative, the assigned independent
review organization shall within one business day forward the information to the
health carrier.

G. Upon receipt of the information from the assigned independent review
organization, the health carrier may reconsider its adverse determination or
final adverse determination. Reconsideration by the health carrier of its
adverse determination or final adverse determination shall not delay or
terminate the external review. The external review may only be terminated if the
health carrier decides to reverse its adverse determination or final adverse
determination and provide coverage or payment for the health care service.
Within one business day after making the decision to reverse its adverse
determination or final adverse determination, the health carrier shall notify
the covered person, his authorized representative, if any, the assigned
independent review organization, and the Commission in writing of its decision.
Upon receipt of the notice of the health carrier&#8217;s decision to reverse its
adverse determination or final adverse determination, the assigned independent
review organization shall terminate the external review.

H. The assigned independent review organization, to the extent the information
or documents are available and the independent review organization considers
them appropriate, shall also consider the following in reaching a decision:

   1. The covered person&#8217;s medical records;

   2. The attending health care professional&#8217;s recommendation;

   3. Consulting reports from appropriate health care professionals and other
   documents submitted by the health carrier, covered person, his authorized
   representative, or the covered person&#8217;s treating provider;

   4. The terms of coverage under the covered person&#8217;s health benefit plan;

   5. The most appropriate practice guidelines, which shall include applicable
   evidence-based standards and may include any other practice guidelines
   developed by the federal government or national or professional medical
   societies, boards, and associations;

   6. Any applicable clinical review criteria developed and used by the health
   carrier or its designee utilization review entity; and

   7. The opinion of the independent review organization&#8217;s clinical
   reviewer or reviewers after considering the information or documents described
   in subdivisions 1 through 6 to the extent the information or documents are
   available and the clinical reviewer or reviewers consider appropriate.
   				In reaching a decision, the assigned independent review organization shall
   not be bound by any decisions or conclusions reached during the health
   carrier&#8217;s utilization review process or the internal appeal process.

I. Within 45 days after the date of receipt of the request for an external
review, the assigned independent review organization shall provide written
notice of its decision to uphold or reverse the adverse determination or the
final adverse determination to the covered person, his authorized
representative, if any, the health carrier, and the Commission. The independent
review organization shall include in such notice: a general description of the
reason for the request for external review; the date the independent review
organization received the assignment from the Commission to conduct the external
review; the date the external review was conducted; the date of its decision;
the principal reason or reasons for its decision, including what applicable, if
any, evidence-based standards were a basis for its decision; the rationale for
its decision; and references to the evidence or documentation, including
evidence-based standards, considered in reaching its decision.

J. Upon receipt of a notice reversing the adverse determination or final adverse
determination, the health carrier promptly shall approve the coverage.

HISTORY: 2011, c. 788; 2019, cc. 826, 840.