2006 Code of Virginia § 32.1-137.7 - Definitions

32.1-137.7. Definitions.

As used in this article:

"Adverse decision" means a utilization review determination by theutilization review entity that a health service rendered or proposed to berendered was or is not medically necessary, when such determination mayresult in noncoverage of the health service or health services. When thepolicy, contract, plan, certificate, or evidence of coverage includescoverage for prescription drugs and the health service rendered or proposedto be rendered is a prescription for the alleviation of cancer pain, anyadverse decision shall be made within twenty-four hours of the request forcoverage.

"Commission" means the Virginia State Corporation Commission.

"Covered person" means a subscriber, policyholder, member, enrollee ordependent, as the case may be, under a policy or contract issued or issuedfor delivery in Virginia by a managed care health insurance plan licensee,insurer, health services plan, or preferred provider organization.

"Evidence of coverage" includes any certificate, individual or groupagreement or contract, or identification card or related documents issued inconjunction with the certificate, agreement or contract, issued to asubscriber setting out the coverage and other rights to which a coveredperson is entitled.

"Final adverse decision" means a utilization review determination made by aphysician advisor or peer of the treating health care provider in areconsideration of an adverse decision, and upon which a provider or patientmay base an appeal.

"Medical director" means a physician licensed to practice medicine in theCommonwealth of Virginia who is an employee of a utilization revieworganization responsible for compliance with the provisions of this article.

"Peer of the treating health care provider" means a physician or otherhealth care professional who holds a nonrestricted license in theCommonwealth of Virginia or under a comparable licensing law of a state ofthe United States and in the same or similar specialty as typically managesthe medical condition, procedure or treatment under review.

"Physician advisor" means a physician licensed to practice medicine in theCommonwealth of Virginia or under a comparable licensing law of a state ofthe United States who provides medical advice or information to a privatereview agent or a utilization review entity in connection with itsutilization review activities.

"Private review agent" means a person or entity performing utilizationreviews, except that the term shall not include the following entities oremployees of any such entity so long as they conduct utilization reviewssolely for subscribers, policyholders, members or enrollees:

1. A health maintenance organization authorized to transact business inVirginia; or

2. A health insurer, hospital service corporation, health services plan orpreferred provider organization authorized to offer health benefits in thisCommonwealth.

"Treating health care provider" or "provider" means a licensed healthcare provider who renders or proposes to render health care services to acovered person.

"Utilization review" means a system for reviewing the necessity,appropriateness and efficiency of hospital, medical or other health careservices rendered or proposed to be rendered to a patient or group ofpatients for the purpose of determining whether such services should becovered or provided by an insurer, health services plan, managed care healthinsurance plan licensee, or other entity or person. For purposes of thisarticle, "utilization review" 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 wereor are to be delivered. "Utilization review" shall not include (i) anyreview of issues concerning insurance contract coverage or contractualrestrictions on facilities to be used for the provision of services, (ii) anyreview of patient information by an employee of or consultant to any licensedhospital for patients of such hospital, or (iii) any determination by aninsurer as to the reasonableness and necessity of services for the treatmentand care of an injury suffered by an insured for which reimbursement isclaimed under a contract of insurance covering any classes of insurancedefined in 38.2-117 through 38.2-119, 38.2-124 through 38.2-126, 38.2-130through 38.2-132 and 38.2-134.

"Utilization review entity" or "entity" means a person or entityperforming utilization review.

"Utilization review plan" or "plan" means a written procedure forperforming review.

(1998, cc. 129, 891; 1999, c. 857; 2000, c. 564.)