2006 Code of Virginia § 32.1-138.6 - Definitions

32.1-138.6. Definitions.

In this chapter the following terms have the meanings indicated:

"Certificate of registration" means a certificate of registration grantedby the Department of Health to a private review agent.

"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.

"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.

"Utilization review" means a system for reviewing the necessity,appropriateness and efficiency of hospital, medical or other health careresources 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, health maintenanceorganization, or other entity or person. For purposes of this article,"utilization review" shall include, but not be limited to, preadmission,concurrent and retrospective medical necessity determination, and reviewrelated to the appropriateness of the site at which services were or are tobe delivered. "Utilization review" shall not include (i) any review ofissues concerning insurance contract coverage or contractual restrictions onfacilities to be used for the provision of services, (ii) any review ofpatient information by an employee of or consultant to any licensed hospitalfor patients of such hospital, or (iii) any determination by an insurer as tothe reasonableness and necessity of services for the treatment and care of aninjury suffered by an insured for which reimbursement is claimed under acontract of insurance covering any classes of insurance defined in 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.

"Utilization review program" means a program for conducting utilizationreviews by a private review agent.

(1990, c. 826, 38.2-5300; 1995, c. 745; 1996, c. 259; 1998, c. 129; 2000,c. 564.)