Peer Utilization Reviews on Reconsideration of an Adverse Decision Frequently Asked Questions

House Bill 11 (HB11) of the 2010 General Assembly session clarifies that a health care provider may seek reconsideration or appeal of an adverse healthcare utilization review decision, and that written notification of an adverse decision must include instructions for requesting reconsideration or an appeal. These amendments to §§ 32.1-137.13, 32.1-137-14, 32.1-137.15 of the Code of Virginia become effective October 1, 2010.

Q. Where can information about HB11 be found?

A. HB11 can be found on Virginia’s Legislative Services website at: http://leg1.state.va.us/000/src.htm

Q. What is required by Managed Care Health Plans (MCHIP) to comply with new amendment?

A. MCHIPs shall revise all complaint and appeals systems to include wording of the new amendment and submit documentation to the MCHIP Unit of OLC for review. Upon determination of compliance, OLC will issue an approval compliance letter. Please contact the Bureau of Insurance for their requirements for revision.

Q. What if utilization review is delegated to another entity?

A. Per 12 VAC 5-408-320, the MCHIP Licensee is responsible for ensuring that the delegated entity complies with the new amendment. Q. Will MCHIPs be penalized if the revisions are submitted after October 1, 2010? A. No. However, the MCHIP is responsible to adhere to the new legislation regardless of receiving an official approval letter from OLC.

Q. Is there a filing fee for submitting the revision?

A. No filing fee is required. Should there be additional questions, MCHIP staff can be reached at 804-367-2102 or at mchip@vdh.virginia.gov.