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 |
Initial Registration
| Form: | |
| Agency Fee: | $0 |
| Required Attachments: |
|
Registration Renewal
| Form: | Form 216-E: Independent Review Organization Application (Renewal) |
| Agency Fee: | $0 |
| Due: | Biennially |
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. |
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 |
Initial Registration
| Form: | |
| Agency Fee: | $500 |
Registration Renewal
| Form: | |
| Agency Fee: | $500 |
| Due: | Biennially by the anniversary of the initial registration date. |
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.
