12 Va. Admin. Code § 5-405-120 - Examination of private review agents
Current through Register Vol.. 38, No. 17, April 11, 2022
A. The department may conduct reviews of the
operations of private review agents operating in this Commonwealth to determine
if the private review agent is operating in compliance with this chapter and
Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code
of Virginia. The reviews may include telephone audits to determine if the
private review agents are accessible as required by this chapter.
B. The department may investigate any
complaint from a health care provider or patient regarding the compliance of a
private review agent with the requirements of this chapter or Article 2.1 of
Chapter 5 of Title 32.1 of the Code of Virginia.
C. The investigation of private review agents
shall not include individual determinations of medical necessity or appropriate
charges for covered services. If there is evidence which indicates an alleged
pattern of misconduct with respect to utilization review performed by a private
review agent, the department may take such action it deems appropriate to
correct such pattern of misconduct.
Notes
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of Virginia.
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