SEARCH SITE

VIRGINIA LAW PORTAL

SEARCHABLE DATABASES

ACROSS SESSIONS

Developed and maintained by the Division of Legislative Automated Systems.

1995 SESSION

  • | print version

HB 1973 Accident and sickness insurance; utilization review.

Introduced by: John Watkins | all patrons    ...    notes | add to my profiles

SUMMARY:

Accident and sickness insurance; utilization review. Establishes standards for utilization review and for appeals from adverse utilization review decisions. The bill requires each entity performing utilization review to develop standards and criteria that are objective, clinically valid and compatible with established principles of health care. Additionally, such entities are required to develop utilization review plans conforming to certain criteria. Utilization review entities are required to be accessible to both patients and providers at least 40 hours per week during normal business hours. Treating providers are to be notified of any adverse utilization review decision within two working days of the decision. Additionally, the bill requires utilization review entities to make good faith efforts to obtain information from providers before rendering adverse decisions.

The bill also establishes methods for (i) reconsideration of any adverse decision and (ii) appeals from such decisions. Decisions on appeals are to be rendered by a peer of the treating health care provider who (i) did not participate in the adverse decision or any prior reconsideration thereof, (ii) is not employed by or a director of the utilization review entity and (iii) is licensed to practice in Virginia or under a comparable licensing law of another state as a peer of the treating health care provider. The bill prohibits penalizing any health care provider who invokes the appeals process or advocates on behalf of his patients to the utilization review entity. Utilization review records must be maintained by the review entity for five years. The Department of Medical Assistance Services' internal utilization review procedures are exempted from most of the bill's requirements.


FULL TEXT

AMENDMENTS

HISTORY