32.1-137.10 - Utilization review plan required. - Virginia Statutes

§ 32.1-137.10. Utilization review plan required.

A. Each utilization review entity subject to this article shall adopt autilization review plan that contains procedures for complying with therequirements and standards of § 32.1-137.9 and other applicable provisions ofthis article. Such plan shall contain, at a minimum, the following:

1. Specific procedures to be used in review determinations, including anexpedited review of no more than twenty-four hours for review determinationsrelating to prescriptions for the alleviation of cancer pain;

2. A provision for advance notice to covered persons of any requirements forcertification of the health care setting or pre-approval of the necessity ofhealth care service or any other prerequisites to approval of payment;

3. A provision for advance notice to covered persons that compliance with thereview process is not a guarantee of benefits or payment under the healthbenefit plan;

4. A provision for a process for reconsideration of adverse decisions inaccordance with § 32.1-137.14 and an appeals process in accordance with §32.1-137.15; and

5. Policies and procedures designed to ensure confidentiality ofpatient-specific medical records and information in accordance withsubsection C of § 32.1-137.12.

B. Each utilization review entity subject to this chapter shall makeavailable to providers and covered persons, upon written request, a copy ofthose portions of its utilization review plan relevant to the specificrequest.

C. The Commissioner shall have the right to determine that an entity hascomplied with the requirement that the entity adopt a utilization review planin accordance with subsection A.

(1998, c. 891; 1999, c. 857.)