                                 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.