Utilization Review Licensing in Virginia

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Virginia. For assistance with licensing, please contact us to learn about our software and managed license services.

Virginia Independent Review Organization Registration

Type of Review:

Medical Utilization Review

Agency:Virginia State Corporation Commission - Bureau of Insurance
Law:

VA Code § 38.2-3566

Foreign Qualification is Prerequisite:Yes
Fact Checked:2/19/21

Initial Registration

Form:

Form 216-E: Independent Review Organization Application

Agency Fee:

$0

Required Attachments:
  • Organization and governing structure of the independent review organization
  • The names of the health carriers for which you conduct independent reviews
  • A copy of your most recent certificate from American Accreditation Healthcare Commission (URAC) Standards for Independent Review Organizations
  • Biographical information for organization officers and directors
  • A list of specific areas of clinical expertise in which you conduct independent reviews, if applicable
  • A copy of your Certificate of Authority to do business in the Commonwealth of Virginia from the Virginia State Corporation Commission Clerk’s Office
  • Schedule of fees
Fact Checked:2/19/21

Registration Renewal

Form:

Form 216-E: Independent Review Organization Application (Renewal)

Agency Fee:

$0

Due:

Biennially

Fact Checked:2/19/21

Supplemental Reporting
Independent Review Organization External Review Annual Report

Form:

Form 216-G: Independent Review Organization External Review Annual Report

Agency Fee:

$0

Due:

Annually by April 1.

Fact Checked:2/19/21

Virginia Private Review Agent (PRA) Certification

Agency:Virginia Department of Health - Office of Licensure and Certification
Law:

VA Code § 32.1-138.7

Foreign Qualification is Prerequisite:Yes
Registered Agent (Special Agency) Required?No
Fact Checked:2/23/21

Initial Registration

Form:

PRA Application

Agency Fee:

$500

Fact Checked:2/23/21

Registration Renewal

Form:

PRA Application (Renewal)

Agency Fee:

$500

Due:

Biennially by the anniversary of the initial registration date.

Fact Checked:2/23/21

Virginia Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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