32.1-137.14 - (Effective until October 1, 2010) Reconsideration of adverse decision.
§ 32.1-137.14. (Effective until October 1, 2010) Reconsideration of adversedecision.
A. Any reconsideration of an adverse decision shall be requested by theprovider on behalf of the covered person. A decision on reconsideration shallbe made by a physician advisor, peer of the treating health care provider, ora panel of other appropriate health care providers with at least onephysician advisor or peer of the treating health care provider on the panel.
The treating provider on behalf of the covered person shall be notified ofthe determination of the reconsideration of the adverse decision, inaccordance with § 32.1-137.9, including the criteria used and the clinicalreason for the adverse decision, the alternate length of treatment of thealternate treatment setting or settings, if any, that the entity deems to beappropriate, and the opportunity for an appeal pursuant to § 32.1-137.15.
B. Any reconsideration shall be rendered and the decision provided to thetreating provider and the covered person in writing within ten working daysof receipt of the request for reconsideration.
(1998, c. 891.)
§ 32.1-137.14. (Effective October 1, 2010) Reconsideration of adversedecision.
A. A treating provider may request reconsideration of an adverse decisionpursuant to this section or may appeal an adverse decision pursuant to §32.1-137.15. Any reconsideration of an adverse decision shall only berequested by the treating provider on behalf of the covered person. Adecision on reconsideration shall be made by a physician advisor, peer of thetreating health care provider, or a panel of other appropriate health careproviders with at least one physician advisor or peer of the treating healthcare provider on the panel.
B. The treating provider on behalf of the covered person shall be (i)notified verbally at the time of the determination of the reconsideration ofthe adverse decision and in writing following the determination of thereconsideration of the adverse decision, in accordance with § 32.1-137.9,including the criteria used and the clinical reason for the adverse decisionand the alternate length of treatment of the alternate treatment setting orsettings, if any, that the entity deems to be appropriate, and (ii) notifiedverbally at the time of the determination of the reconsideration of theadverse decision of the process for an appeal of the determination pursuantto § 32.1-137.15 and the contact name, address, and telephone number to fileand perfect an appeal. If the treating provider on behalf of the coveredperson requests that the adverse decision be reviewed by a peer of thetreating provider at any time during the reconsideration process, the requestfor reconsideration shall be vacated and considered an appeal pursuant to §32.1-137.15. In such cases, the covered person shall be notified that thereconsideration has been vacated and an appeal initiated, all documentationand information provided or relied upon during the reconsideration processpursuant to this section shall be converted to the appeal process, and noadditional actions shall be required of the treating provider to perfect theappeal.
C. Any reconsideration shall be rendered and the decision provided to thetreating provider and the covered person in writing within 10 working days ofreceipt of the request for reconsideration.
(1998, c. 891; 2010, c. 395.)