                                 CODE OF VIRGINIA

EXPEDITED EXTERNAL REVIEW (§ 38.2-3562)

A. A covered person or his authorized representative may make a request for an
expedited external review with the Commission at the time the covered person
receives:

   1. An adverse determination if the adverse determination involves (i) cancer
   or (ii) a medical condition of the covered person for which the time frame for
   completion of an expedited internal appeal involving an adverse determination
   would seriously jeopardize the life or health of the covered person or would
   jeopardize the covered person&#8217;s ability to regain maximum function, and
   the covered person or his authorized representative has filed a request for an
   expedited internal appeal of the adverse determination; or

   2. A final adverse determination if the covered person has (i) cancer or (ii)
   a medical condition where the time frame for completion of a standard external
   review would seriously jeopardize the life or health of the covered person or
   would jeopardize the covered person&#8217;s ability to regain maximum
   function, or if the final adverse determination concerns an admission,
   availability of care, continued stay, or health care service for which the
   covered person received emergency services, but has not been discharged from a
   facility.

B. Upon receipt of a request for an expedited external review, the Commission
shall promptly send a copy of the request to the health carrier. Promptly upon
receipt of such request, the health carrier shall determine whether the request
meets the eligibility requirements in subsection B of &#xA7; 38.2-3561. The
health carrier shall promptly notify the Commission, the covered person, and his
authorized representative, if any, of its eligibility determination. 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 such determination, the Commission decision shall be made in
accordance with the terms of the covered person&#8217;s health benefit plan and
the requirements of subsection B of &#xA7; 38.2-3561.
			Upon receipt of the notice that the request meets the eligibility
requirements, the Commission shall promptly assign an independent review
organization to conduct the expedited external review. The Commission shall
promptly notify the health carrier of the name of the assigned independent
review organization.

C. Promptly upon receipt of the notice from the Commission of the name of the
independent review organization assigned, the health carrier or its designee
utilization review entity shall provide or transmit all necessary documents and
information considered in making the adverse determination or final adverse
determination to the assigned independent review organization electronically, by
telephone, facsimile, or any other available expeditious method.

D. 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 pertinent 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
   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 in making adverse
   determinations; and

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

E. As expeditiously as the covered person&#8217;s medical condition or
circumstances requires, but in no event more than 72 hours after the date of
receipt of an eligible request for an expedited external review, the assigned
independent review organization shall make a decision to uphold or reverse the
adverse determination or final adverse determination and notify the covered
person, his authorized representative, if any, the health carrier, and the
Commission. If such decision was not in writing, within 48 hours after the date
of providing such decision, the assigned independent review organization shall
provide written confirmation of the decision to the covered person, his
authorized representative, if any, the health carrier, and the Commission and
include the information set forth in subsection I of &#xA7; 38.2-3561.

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

G. An expedited external review shall not be available for retrospective adverse
determinations or retrospective final adverse determinations.

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