"Covered person" means an individual, whether a policyholder, subscriber,enrollee, covered dependent, or member of a managed care health insuranceplan, who is entitled to health care services or benefits provided, arrangedfor, paid for or reimbursed pursuant to a managed care health insurance planas defined in and subject to regulation under Chapter 58, when such coverageis provided under a contract issued in this Commonwealth.
"Final adverse decision" means a utilization review determination denyingbenefits or coverage, and concerning which all internal appeals available tothe covered person pursuant to Title 32.1 have been exhausted.
"Treating health care provider" means a licensed health care provider whorenders or proposes to render health care services to a covered person.
"Utilization review" means a system for reviewing the necessity,appropriateness and efficiency of hospital, medical or other health careservices rendered or proposed to be rendered to a patient or group ofpatients for the purpose of determining whether such services should becovered or provided by an insurer, health services plan, managed care healthinsurance plan licensee, or other entity or person. For purposes of thischapter, "utilization review" shall include, but not be limited to,preadmission, concurrent and retrospective medical necessity determination,and review related to the appropriateness of the site at which services wereor are to be delivered. "Utilization review" shall also includedeterminations of medical necessity based upon contractual limitationsregarding "experimental" or "investigational" procedures, by whateverterms designated in the evidence of coverage. "Utilization review" shallnot include (i) any denial of benefits or services for a procedure which isexplicitly excluded pursuant to the terms of the contract or evidence ofcoverage, (ii) any review of issues concerning contractual restrictions onfacilities to be used for the provision of services, or (iii) anydetermination by an insurer as to the reasonableness and necessity ofservices for the treatment and care of an injury suffered by an insured forwhich reimbursement is claimed under a contract in insurance covering anyclasses of insurance defined in §§ 38.2-117, 38.2-118, 38.2-119, 38.2-124,38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132, and 38.2-134.
"Utilization review entity" means an insurer or managed care healthinsurance plan licensee that performs utilization review or upon whose behalfutilization review is performed with regard to the health care or proposedhealth care that is the subject of the final adverse decision.
"Covered person" means an individual, whether a policyholder, subscriber,enrollee, covered dependent, or member of a managed care health insuranceplan, who is entitled to health care services or benefits provided, arrangedfor, paid for or reimbursed pursuant to a managed care health insurance planas defined in and subject to regulation under Chapter 58, when such coverageis provided under a contract issued in this Commonwealth.
"Final adverse decision" means a utilization review determination denyingbenefits or coverage, and concerning which all internal appeals available tothe covered person pursuant to Title 32.1 have been exhausted.
"Treating health care provider" means a licensed health care provider whorenders or proposes to render health care services to a covered person.
"Utilization review" means a system for reviewing the necessity,appropriateness and efficiency of hospital, medical or other health careservices rendered or proposed to be rendered to a patient or group ofpatients for the purpose of determining whether such services should becovered or provided by an insurer, health services plan, managed care healthinsurance plan licensee, or other entity or person. For purposes of thischapter, "utilization review" shall include, but not be limited to,preadmission, concurrent and retrospective medical necessity determination,and review related to the appropriateness of the site at which services wereor are to be delivered. "Utilization review" shall also includedeterminations of medical necessity based upon contractual limitationsregarding "experimental" or "investigational" procedures, by whateverterms designated in the evidence of coverage. "Utilization review" shallnot include (i) any denial of benefits or services for a procedure which isexplicitly excluded pursuant to the terms of the contract or evidence ofcoverage, (ii) any review of issues concerning contractual restrictions onfacilities to be used for the provision of services, or (iii) anydetermination by an insurer as to the reasonableness and necessity ofservices for the treatment and care of an injury suffered by an insured forwhich reimbursement is claimed under a contract in insurance covering anyclasses of insurance defined in §§ 38.2-117, 38.2-118, 38.2-119, 38.2-124,38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132, and 38.2-134.
"Utilization review entity" means an insurer or managed care healthinsurance plan licensee that performs utilization review or upon whose behalfutilization review is performed with regard to the health care or proposedhealth care that is the subject of the final adverse decision.
"Covered person" means an individual, whether a policyholder, subscriber,enrollee, covered dependent, or member of a managed care health insuranceplan, who is entitled to health care services or benefits provided, arrangedfor, paid for or reimbursed pursuant to a managed care health insurance planas defined in and subject to regulation under Chapter 58, when such coverageis provided under a contract issued in this Commonwealth.
"Final adverse decision" means a utilization review determination denyingbenefits or coverage, and concerning which all internal appeals available tothe covered person pursuant to Title 32.1 have been exhausted.
"Treating health care provider" means a licensed health care provider whorenders or proposes to render health care services to a covered person.
"Utilization review" means a system for reviewing the necessity,appropriateness and efficiency of hospital, medical or other health careservices rendered or proposed to be rendered to a patient or group ofpatients for the purpose of determining whether such services should becovered or provided by an insurer, health services plan, managed care healthinsurance plan licensee, or other entity or person. For purposes of thischapter, "utilization review" shall include, but not be limited to,preadmission, concurrent and retrospective medical necessity determination,and review related to the appropriateness of the site at which services wereor are to be delivered. "Utilization review" shall also includedeterminations of medical necessity based upon contractual limitationsregarding "experimental" or "investigational" procedures, by whateverterms designated in the evidence of coverage. "Utilization review" shallnot include (i) any denial of benefits or services for a procedure which isexplicitly excluded pursuant to the terms of the contract or evidence ofcoverage, (ii) any review of issues concerning contractual restrictions onfacilities to be used for the provision of services, or (iii) anydetermination by an insurer as to the reasonableness and necessity ofservices for the treatment and care of an injury suffered by an insured forwhich reimbursement is claimed under a contract in insurance covering anyclasses of insurance defined in §§ 38.2-117, 38.2-118, 38.2-119, 38.2-124,38.2-125, 38.2-126, 38.2-130, 38.2-131, 38.2-132, and 38.2-134.
"Utilization review entity" means an insurer or managed care healthinsurance plan licensee that performs utilization review or upon whose behalfutilization review is performed with regard to the health care or proposedhealth care that is the subject of the final adverse decision.
