Terms Used In Virginia Code > Title 15.2 > Subtitle II > Chapter 13 > Article 2 - Local Government Associations.

• Accident and sickness insurance: means insurance against loss resulting from sickness, or from bodily injury or death by accident or accidental means, or from a combination of any or all of these perils. See Virginia Code 38.2-109
• Adverse determination: means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. See Virginia Code 38.2-3556
• Ambulatory review: means utilization review of health care services performed or provided in an outpatient setting. See Virginia Code 38.2-3556
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Virginia Code 38.2-3556
• Best evidence: means evidence based on (i) randomized clinical trials; if randomized clinical trials are not available, then (ii) cohort studies or case-control studies; if clauses (i) and (ii) are not available, then (iii) case-series; or if clauses (i), (ii), and (iii) are not available, then (iv) expert opinion. See Virginia Code 38.2-3556
• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Virginia Code 38.2-3556
• Case-series: means an evaluation of a series of patients with a particular outcome, without the use of a control group. See Virginia Code 38.2-3556
• Certification: means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness. See Virginia Code 38.2-3556
• Commission: means the State Corporation Commission. See Virginia Code 38.2-100
• Company: means any association, aggregate of individuals, business, corporation, individual, joint-stock company, Lloyds type of organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Virginia Code 38.2-100
• Concurrent review: means utilization review conducted during a patient's hospital stay or course of treatment. See Virginia Code 38.2-3556
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Virginia Code 38.2-3556
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility. See Virginia Code 38.2-3556
• Emergency medical condition: means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions or a serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. See Virginia Code 38.2-3556
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Expert opinion: means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. See Virginia Code 38.2-3556
• Facility: means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings. See Virginia Code 38.2-3556
• Governing body: means the board of supervisors of a county, council of a city, or council of a town, as the context may require. See Virginia Code 15.2-102
• Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Virginia Code 38.2-3556
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the laws of the Commonwealth. See Virginia Code 38.2-3556
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Virginia Code 38.2-3556
• Health carrier: means an entity, subject to the insurance laws and regulations of the Commonwealth or subject to the jurisdiction of the Commission, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an accident and sickness insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or any other entity providing a plan of health insurance, health benefits, or health care services except as excluded under § Virginia Code 38.2-3556
• Health services plan: means any arrangement for offering or administering health services or similar or related services by a corporation licensed under Virginia Code 38.2-100
• Includes: means includes, but not limited to. See Virginia Code 1-218
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Lien: A claim against real or personal property in satisfaction of a debt.
• local government: shall be construed to mean a county, city, or town as the context may require. See Virginia Code 15.2-102
• Locality: means a county, city, or town as the context may require. See Virginia Code 1-221
• Medical or scientific evidence: means evidence found in (i) peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; (ii) peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. See Virginia Code 38.2-3556
• Medicare: means the "Health Insurance for the Aged Act" Title XVIII of the Social Security Amendment of 1965, as amended. See Virginia Code 38.2-100
• Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds type of organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Virginia Code 38.2-100
• Process: includes subpoenas, the summons and complaint in a civil action, and process in statutory actions. See Virginia Code 1-237
• Prospective review: means utilization review conducted prior to an admission or a course of treatment. See Virginia Code 38.2-3556
• provider: means a health care professional or a facility. See Virginia Code 38.2-3556
• real estate: includes lands, tenements and hereditaments, and all rights and appurtenances thereto and interests therein, other than a chattel interest. See Virginia Code 1-219
• Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
• Retrospective review: means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment. See Virginia Code 38.2-3556
• Second opinion: means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service. See Virginia Code 38.2-3556
• State: when applied to a part of the United States, includes any of the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Northern Mariana Islands, and the United States Virgin Islands. See Virginia Code 1-245
• Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201
• United States: includes the 50 states, the District of Columbia the Commonwealth of Puerto Rico, Guam, the Northern Mariana Islands and the United States Virgin Islands. See Virginia Code 1-255
• Utilization review: means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. See Virginia Code 38.2-3556
• Utilization review entity: means an individual or entity that conducts utilization review. See Virginia Code 38.2-3556