§ 32.1-137.13 — Adverse determination

Virginia § 32.1-137.13

• Jurisdiction: Virginia
• Title 32.1: HEALTH
• Ch. 5: REGULATION OF MEDICAL CARE FACILITIES AND SERVICES
• Art. 1.2: UTILIZATION REVIEW STANDARDS AND APPEALS

Text

A. The treating provider shall be notified in writing of any adverse determination within two working days of the determination; however, the treating provider shall be notified orally by telephone within 24 hours of any adverse determination for a prescription known to be for the alleviation of cancer pain. Any such notification shall include instructions for the provider on behalf of the covered person to (i) seek a reconsideration of the adverse determination pursuant to § 32.1-137.14, including the contact name, address, and telephone number of the person responsible for making the adverse determination, and (ii) seek an appeal of the adverse determination pursuant to § 32.1-137.15, including the contact name, address, and telephone number to file and perfect such appeal.

B. No entity shall render an adverse determination unless it has made a good faith attempt to obtain information from the provider. At any time before the entity renders its determination, the provider shall be entitled to review the issue of medical necessity with a physician advisor or peer of the treating health care provider who represents the entity. For any adverse determination relating to a prescription to alleviate cancer pain, a physician advisor shall review the issue of medical necessity with the provider.

Legislative History

1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395; 2011, c. 788.