A. The Bureau of Insurance shall contract with one or more impartial healthentities for the purpose of performing the review of final adverse decisions.The Commission shall adopt regulations to assure that the impartial healthentity conducting the review has adequate standards, credentials andexperience for such review. The impartial health entity shall examine thefinal adverse decision to determine whether the decision is objective,clinically valid, compatible with established principles of health care, andappropriate under the terms of the contractual obligations to the coveredperson. The impartial health entity shall review the written appeal; theresponse of the utilization review entity; any affidavits which either thecovered person, the treating health care provider, or the utilization reviewentity may file with the Bureau of Insurance; and such medical records as theimpartial health entity shall deem appropriate. The impartial health entityshall issue its written recommendation affirming, modifying or reversing thefinal adverse decision within 30 working days of the date that the impartialreview entity has received from all parties all documentation and informationnecessary for it to complete its review. The Commissioner or his designee,based upon such recommendation, shall issue a written ruling affirming,modifying or reversing the final adverse decision within 10 working daysafter his receipt of the recommendation of the impartial review entity;however, if the regular process for the issuance of such written ruling willdelay the rendering of treatment for a patient whose condition would beterminal without the treatment, the Commissioner or his designee shall issuehis written ruling affirming, modifying, or reversing the final adversedecision no later than one business day following the receipt of suchrecommendation. Such written ruling shall not be construed as a finalfinding, order or judgment of the Commission, and shall be exempt from theapplication of the Administrative Process Act (§ 2.2-4000 et seq.). Thewritten ruling of the Commissioner or his designee shall affirm therecommendations of the impartial health entity unless the Commissioner or hisdesignee finds in his ruling that the impartial health entity exceeded itsauthority or acted arbitrarily or capriciously. The written ruling of theCommissioner or his designee shall bind the covered person and theutilization review entity to the extent to which each would have beenobligated by a judgment entered in an action at law or in equity with respectto the issues which the impartial review entity may examine when reviewing afinal adverse decision under this section. Failure by the utilization reviewentity to comply with the written ruling of the Commissioner or his designeewithin 30 days of the date of such ruling, or within three business daysfollowing receipt by the utilization review entity of an expedited rulingshall be deemed a knowing and willful violation of this section. Theimpartial health entity shall not be affiliated or a subsidiary of, nor ownedor controlled by, a health plan, a trade association of health plans, or aprofessional association of health care providers.
B. The Bureau of Insurance shall contract with one or more impartial healthentities such as medical peer review organizations and independentutilization review companies which the Bureau of Insurance shall determine topossess the necessary credentials and otherwise be qualified to perform suchreview. Prior to assigning an appeal to an impartial health entity, theBureau of Insurance shall verify that the impartial health entity conductingthe review of a final adverse decision has no relationship or associationwith (i) the utilization review entity, or any officer, director or managerof such utilization review entity, (ii) the covered person, (iii) thetreating health care provider, or any of its employees or affiliates, (iv)the medical care facility at which the covered service would be provided, orany of its employees or affiliates, or (v) the development or manufacture ofthe drug, device, procedure or other therapy which is the subject of thefinal adverse decision. The impartial health entity shall not be a subsidiaryof, nor owned or controlled by, a health plan, a trade association of healthplans, or a professional association of health care providers.
C. There shall be no liability on the part of and no cause of action shallarise against any officer or employee of an impartial health entity for anyactions taken or not taken or statements made by such officer or employee ingood faith in the performance of his powers and duties.
D. Any utilization review entity that is required to provide previouslydenied services as a result of the review by the impartial health entityshall be subject to payment of such fees as the Commissioner, in his solediscretion, shall deem appropriate to cover the costs of the review. All suchfees shall be collected by the Bureau of Insurance and paid directly into thestate treasury and credited to the fund for the maintenance of the Bureau ofInsurance as provided in subsection B of § 38.2-400. Failure by theutilization review entity to remit such fee within thirty days of the datenotice of such fee is mailed to the utilization review entity shall be deemeda knowing and willful violation of this section.
(1999, cc. 643, 649; 2000, c. 922; 2002, c. 745; 2007, c. 346.)
A. The Bureau of Insurance shall contract with one or more impartial healthentities for the purpose of performing the review of final adverse decisions.The Commission shall adopt regulations to assure that the impartial healthentity conducting the review has adequate standards, credentials andexperience for such review. The impartial health entity shall examine thefinal adverse decision to determine whether the decision is objective,clinically valid, compatible with established principles of health care, andappropriate under the terms of the contractual obligations to the coveredperson. The impartial health entity shall review the written appeal; theresponse of the utilization review entity; any affidavits which either thecovered person, the treating health care provider, or the utilization reviewentity may file with the Bureau of Insurance; and such medical records as theimpartial health entity shall deem appropriate. The impartial health entityshall issue its written recommendation affirming, modifying or reversing thefinal adverse decision within 30 working days of the date that the impartialreview entity has received from all parties all documentation and informationnecessary for it to complete its review. The Commissioner or his designee,based upon such recommendation, shall issue a written ruling affirming,modifying or reversing the final adverse decision within 10 working daysafter his receipt of the recommendation of the impartial review entity;however, if the regular process for the issuance of such written ruling willdelay the rendering of treatment for a patient whose condition would beterminal without the treatment, the Commissioner or his designee shall issuehis written ruling affirming, modifying, or reversing the final adversedecision no later than one business day following the receipt of suchrecommendation. Such written ruling shall not be construed as a finalfinding, order or judgment of the Commission, and shall be exempt from theapplication of the Administrative Process Act (§ 2.2-4000 et seq.). Thewritten ruling of the Commissioner or his designee shall affirm therecommendations of the impartial health entity unless the Commissioner or hisdesignee finds in his ruling that the impartial health entity exceeded itsauthority or acted arbitrarily or capriciously. The written ruling of theCommissioner or his designee shall bind the covered person and theutilization review entity to the extent to which each would have beenobligated by a judgment entered in an action at law or in equity with respectto the issues which the impartial review entity may examine when reviewing afinal adverse decision under this section. Failure by the utilization reviewentity to comply with the written ruling of the Commissioner or his designeewithin 30 days of the date of such ruling, or within three business daysfollowing receipt by the utilization review entity of an expedited rulingshall be deemed a knowing and willful violation of this section. Theimpartial health entity shall not be affiliated or a subsidiary of, nor ownedor controlled by, a health plan, a trade association of health plans, or aprofessional association of health care providers.
B. The Bureau of Insurance shall contract with one or more impartial healthentities such as medical peer review organizations and independentutilization review companies which the Bureau of Insurance shall determine topossess the necessary credentials and otherwise be qualified to perform suchreview. Prior to assigning an appeal to an impartial health entity, theBureau of Insurance shall verify that the impartial health entity conductingthe review of a final adverse decision has no relationship or associationwith (i) the utilization review entity, or any officer, director or managerof such utilization review entity, (ii) the covered person, (iii) thetreating health care provider, or any of its employees or affiliates, (iv)the medical care facility at which the covered service would be provided, orany of its employees or affiliates, or (v) the development or manufacture ofthe drug, device, procedure or other therapy which is the subject of thefinal adverse decision. The impartial health entity shall not be a subsidiaryof, nor owned or controlled by, a health plan, a trade association of healthplans, or a professional association of health care providers.
C. There shall be no liability on the part of and no cause of action shallarise against any officer or employee of an impartial health entity for anyactions taken or not taken or statements made by such officer or employee ingood faith in the performance of his powers and duties.
D. Any utilization review entity that is required to provide previouslydenied services as a result of the review by the impartial health entityshall be subject to payment of such fees as the Commissioner, in his solediscretion, shall deem appropriate to cover the costs of the review. All suchfees shall be collected by the Bureau of Insurance and paid directly into thestate treasury and credited to the fund for the maintenance of the Bureau ofInsurance as provided in subsection B of § 38.2-400. Failure by theutilization review entity to remit such fee within thirty days of the datenotice of such fee is mailed to the utilization review entity shall be deemeda knowing and willful violation of this section.
(1999, cc. 643, 649; 2000, c. 922; 2002, c. 745; 2007, c. 346.)
A. The Bureau of Insurance shall contract with one or more impartial healthentities for the purpose of performing the review of final adverse decisions.The Commission shall adopt regulations to assure that the impartial healthentity conducting the review has adequate standards, credentials andexperience for such review. The impartial health entity shall examine thefinal adverse decision to determine whether the decision is objective,clinically valid, compatible with established principles of health care, andappropriate under the terms of the contractual obligations to the coveredperson. The impartial health entity shall review the written appeal; theresponse of the utilization review entity; any affidavits which either thecovered person, the treating health care provider, or the utilization reviewentity may file with the Bureau of Insurance; and such medical records as theimpartial health entity shall deem appropriate. The impartial health entityshall issue its written recommendation affirming, modifying or reversing thefinal adverse decision within 30 working days of the date that the impartialreview entity has received from all parties all documentation and informationnecessary for it to complete its review. The Commissioner or his designee,based upon such recommendation, shall issue a written ruling affirming,modifying or reversing the final adverse decision within 10 working daysafter his receipt of the recommendation of the impartial review entity;however, if the regular process for the issuance of such written ruling willdelay the rendering of treatment for a patient whose condition would beterminal without the treatment, the Commissioner or his designee shall issuehis written ruling affirming, modifying, or reversing the final adversedecision no later than one business day following the receipt of suchrecommendation. Such written ruling shall not be construed as a finalfinding, order or judgment of the Commission, and shall be exempt from theapplication of the Administrative Process Act (§ 2.2-4000 et seq.). Thewritten ruling of the Commissioner or his designee shall affirm therecommendations of the impartial health entity unless the Commissioner or hisdesignee finds in his ruling that the impartial health entity exceeded itsauthority or acted arbitrarily or capriciously. The written ruling of theCommissioner or his designee shall bind the covered person and theutilization review entity to the extent to which each would have beenobligated by a judgment entered in an action at law or in equity with respectto the issues which the impartial review entity may examine when reviewing afinal adverse decision under this section. Failure by the utilization reviewentity to comply with the written ruling of the Commissioner or his designeewithin 30 days of the date of such ruling, or within three business daysfollowing receipt by the utilization review entity of an expedited rulingshall be deemed a knowing and willful violation of this section. Theimpartial health entity shall not be affiliated or a subsidiary of, nor ownedor controlled by, a health plan, a trade association of health plans, or aprofessional association of health care providers.
B. The Bureau of Insurance shall contract with one or more impartial healthentities such as medical peer review organizations and independentutilization review companies which the Bureau of Insurance shall determine topossess the necessary credentials and otherwise be qualified to perform suchreview. Prior to assigning an appeal to an impartial health entity, theBureau of Insurance shall verify that the impartial health entity conductingthe review of a final adverse decision has no relationship or associationwith (i) the utilization review entity, or any officer, director or managerof such utilization review entity, (ii) the covered person, (iii) thetreating health care provider, or any of its employees or affiliates, (iv)the medical care facility at which the covered service would be provided, orany of its employees or affiliates, or (v) the development or manufacture ofthe drug, device, procedure or other therapy which is the subject of thefinal adverse decision. The impartial health entity shall not be a subsidiaryof, nor owned or controlled by, a health plan, a trade association of healthplans, or a professional association of health care providers.
C. There shall be no liability on the part of and no cause of action shallarise against any officer or employee of an impartial health entity for anyactions taken or not taken or statements made by such officer or employee ingood faith in the performance of his powers and duties.
D. Any utilization review entity that is required to provide previouslydenied services as a result of the review by the impartial health entityshall be subject to payment of such fees as the Commissioner, in his solediscretion, shall deem appropriate to cover the costs of the review. All suchfees shall be collected by the Bureau of Insurance and paid directly into thestate treasury and credited to the fund for the maintenance of the Bureau ofInsurance as provided in subsection B of § 38.2-400. Failure by theutilization review entity to remit such fee within thirty days of the datenotice of such fee is mailed to the utilization review entity shall be deemeda knowing and willful violation of this section.
(1999, cc. 643, 649; 2000, c. 922; 2002, c. 745; 2007, c. 346.)
