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2001 SESSION

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CHAPTER 22 An Act to amend and reenact § 32.1-137.13 of the Code of Virginia, relating to health insurance; adverse decisions. [S 955] Approved March 2, 2001

Be it enacted by the General Assembly of Virginia:

1. That § 32.1-137.13 of the Code of Virginia is amended and reenacted as follows:

§ 32.1-137.13. Adverse decision.

A. The treating provider shall be notified in writing of any adverse decision within two working days of the decision; however, the treating provider shall be notified orally by telephone within twenty-four hours of any adverse decision for a prescription known to be for the alleviation of cancer pain. Any such notification shall include instructions for the provider on behalf of the covered person to seek a reconsideration of the adverse decision, including a the contact name, address, and telephone number of the person responsible for making the adverse decision.

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