32.1-137.13 - Adverse decision. - Virginia Statutes

§ 32.1-137.13. Adverse decision.

A. (Effective until October 1, 2010) The treating provider shall be notifiedin writing of any adverse decision within two working days of the decision;however, the treating provider shall be notified orally by telephone withintwenty-four hours of any adverse decision for a prescription known to be forthe alleviation of cancer pain. Any such notification shall includeinstructions for the provider on behalf of the covered person to seek areconsideration of the adverse decision, including the contact name, address,and telephone number of the person responsible for making the adversedecision.

A. (Effective October 1, 2010) The treating provider shall be notified inwriting of any adverse decision within two working days of the decision;however, the treating provider shall be notified orally by telephone within24 hours of any adverse decision for a prescription known to be for thealleviation of cancer pain. Any such notification shall include instructionsfor the provider on behalf of the covered person to (i) seek areconsideration of the adverse decision pursuant to § 32.1-137.14, includingthe contact name, address, and telephone number of the person responsible formaking the adverse decision, and (ii) seek an appeal of the adverse decisionpursuant to § 32.1-137.15, including the contact name, address, and telephonenumber to file and perfect such appeal.

B. No entity shall render an adverse decision unless it has made a good faithattempt to obtain information from the provider. At any time before theentity renders its decision, the provider shall be entitled to review theissue of medical necessity with a physician advisor or peer of the treatinghealth care provider who represents the entity. For any adverse decisionrelating to a prescription to alleviate cancer pain, a physician advisorshall review the issue of medical necessity with the provider.

(1998, c. 891; 1999, c. 857; 2001, c. 22; 2010, c. 395.)