32.1-137.9 - Requirements and standards for utilization review entities.
§ 32.1-137.9. Requirements and standards for utilization review entities.
A. Each entity shall establish reasonable and prudent standards and criteriato be applied in utilization review determinations with input from physicianadvisors representing major areas of specialty and certified by the boards ofthe various American medical specialties. Such standards shall be objective,clinically valid, and compatible with established principles of health care.Such standards shall further be established so as to be sufficiently flexibleto allow deviations from norms when justified on case-by-case bases.
The entity shall make available to any provider or covered person, uponwritten request, a list of such physician advisors and their major areas ofspecialty, as well as the standards and criteria established in accordancewith this section except as prohibited in accordance with copyright laws.
B. An adverse decision shall be made only in accordance with § 32.1-137.13.
C. Each entity shall have a process for reconsideration of an adversedecision in accordance with § 32.1-137.14 and an appeals process inaccordance with § 32.1-137.15.
D. Each entity shall make arrangements to use the services of physicianadvisors who are specialists in the various categories of health care on"per need" or "as needed" bases in conducting utilization review.
E. Each entity shall have review staff who are properly qualified, trainedand supervised, and supported by a physician advisor, to carry out its reviewdeterminations.
F. Each entity shall notify its covered persons of the review process,including the appeals process, and shall so notify the covered person'sprovider upon written request by the provider. An Evidence of Coverage shallcontain a clear and complete statement, if a contract, or a reasonablycomplete summary, if a certificate, of the process for reconsideration of anadverse decision rendered under § 32.1-137.13, as required by § 32.1-137.14,and the process for appeal from a final adverse decision under § 32.1-137.15.
G. Each entity shall communicate its utilization review decision no laterthan two business days after receipt by the entity of all informationnecessary to complete the review.
H. Each entity shall have a representative, authorized to approve utilizationreview determinations, available to covered persons and providers inaccordance with § 32.1-137.11.
I. The Commissioner shall have the right to determine that an entity hascomplied with the requirement that the entity establish reasonable andprudent requirements and standards pursuant to this section.
(1998, c. 891.)