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:

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

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:

PRA Application

Agency Fee:

$500

Registration Renewal

Form:

PRA Application (Renewal)

Agency Fee:

$500

Due:

Biennially by the anniversary of the initial registration date.

Virginia Resources

Annual Report Apostille - Authentication Architecture Firm License Articles of Incorporation Articles of Organization Business License Certificate of Authority Certificate of Cancellation Service Certificate of Good Standing / Existence Certificate of Merger Certification - Authentication Change Your Registered Agent
Charitable Gaming License Charitable Gift Annuity Licensing Compliance Charitable Registration Construction License Converting Your Entity Corporation LLC Nonprofit Amendment Dissolve Corporation LLC Nonprofit Employer (Payroll & Withholding Tax) Registration Service Employment Agency Licensing Energy Licensing Engineering Firm License Entity Name Reservation
Fictitious Name Registration & Renewal Foreign Corporation Foreign LLC Healthcare and Pharmaceutical Licenses How to File Articles of Incorporation How to Form an LLC How to Incorporate How to Start a Nonprofit Organization Insurance Licensing Licensing Resources Moving Your Company's Domicile to Nonprofit Articles of Incorporation
Nonprofit Compliance Obtain Certified Copies Private Investigator License Real Estate Licensing Registered Agent Service Reinstate Corporation LLC Nonprofit Sales & Use Tax Registration Service Sales Tax Exemption Start a Business Tax Clearance Certificate Tax Exemption Utilization Review Certification / License

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.

Revised February 23, 2021. Complete data last reviewed February 19, 2021.
Stay Informed
Get our industry-leading insights, research, and educational content first!
Contact
Contact
Better Business Bureau logo
Trustwave logo
© 2012 - 2021 Harbor Compliance. All rights reserved. Harbor Compliance does not provide tax, financial, or legal advice. Use of our services does not create an attorney-client relationship. Harbor Compliance is not acting as your attorney and does not review information you provide to us for legal accuracy or sufficiency. Access to our website is subject to our Terms of Use and Service Agreement.
Terms of Service Privacy Policy Secure Shopping