Terms Used In Virginia Code > Title 32.1 > Chapter 5 - Regulation of Medical Care Facilities and Services

• Adverse determination: means a determination by the managed care health insurance plan or its designee utilization review entity that, based upon information provided, a request for a benefit upon application of any utilization review technique does not meet the managed care health insurance plan's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit. See Virginia Code 32.1-137.7
• Antique motor vehicle: means every motor vehicle, as defined in this section, which was actually manufactured or designated by the manufacturer as a model manufactured in a calendar year not less than 25 years prior to January 1 of each calendar year and is owned solely as a collector's item. See Virginia Code 46.2-100
• Auto recycler: means any person licensed by the Commonwealth to engage in business as a salvage dealer, rebuilder, demolisher, or scrap metal processor. See Virginia Code 46.2-1600
• Certified nursing facility: means any skilled nursing facility, skilled care facility, intermediate care facility, nursing or nursing care facility, or nursing home, whether freestanding or a portion of a freestanding medical care facility, that is certified as a Medicare or Medicaid provider, or both, pursuant to § Virginia Code 32.1-123
• Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
• Commission: means the Virginia State Corporation Commission. See Virginia Code 32.1-137.7
• Covered person: means a subscriber, policyholder, member, enrollee or dependent, as the case may be, under a policy or contract issued or issued for delivery in Virginia by a managed care health insurance plan licensee, insurer, health services plan, or preferred provider organization. See Virginia Code 32.1-137.7
• Demolisher: means any person whose business is to crush, flatten, bale, shred, log, or otherwise reduce a vehicle to a state where it can no longer be considered a vehicle. See Virginia Code 46.2-1600
• Department: means the State Department of Health. See Virginia Code 32.1-3
• entity: means a person or entity performing utilization review. See Virginia Code 32.1-137.7
• Grand jury: agreement providing that a lender will delay exercising its rights (in the case of a mortgage,
• Health care professional: means any professional who is licensed, certified or registered to practice by a board within the Department of Health Professions under Virginia Code 32.1-162.7
• Home care organization: means a public or private organization, whether operated for profit or not for profit, that provides, at the residence of a patient or individual in the Commonwealth of Virginia, one or more of the following services:

  1. See Virginia Code 32.1-162.7

• Hospice: means a coordinated program of home and inpatient care provided directly or through an agreement under the direction of an identifiable hospice administration providing palliative and supportive medical and other health services to terminally ill patients and their families. See Virginia Code 32.1-162.1
• Hospice facility: means an institution, place, or building owned or operated by a hospice provider and licensed by the Department to provide room, board, and appropriate hospice care on a 24-hour basis, including respite and symptom management, to individuals requiring such care pursuant to the orders of a physician. See Virginia Code 32.1-162.1
• Hospice patient: means a diagnosed terminally ill patient, with an anticipated life expectancy of six months or less, who, alone or in conjunction with designated family members, has voluntarily requested admission and been accepted into a licensed hospice program. See Virginia Code 32.1-162.1
• Hospital: means any facility licensed pursuant to this article in which the primary function is the provision of diagnosis, of treatment, and of medical and nursing services, surgical or nonsurgical, for two or more nonrelated individuals, including hospitals known by varying nomenclature or designation such as children's hospitals, sanatoriums, sanitariums and general, acute, rehabilitation, chronic disease, short-term, long-term, outpatient surgical, and inpatient or outpatient maternity hospitals. See Virginia Code 32.1-123
• Identifiable hospice administration: means an administrative group, individual or legal entity that has a distinct organizational structure, accountable to the governing authority directly or through a chief executive officer. See Virginia Code 32.1-162.1
• Immediate and serious threat: means a situation or condition having a high probability that serious harm or injury to patients could occur at any time, or already has occurred, and may occur again, if patients are not protected effectively from the harm, or the threat is not removed. See Virginia Code 32.1-123
• Independent appraisal firm: means any business providing cost estimates for the repair of damaged motor vehicles for insurance purposes and having all required business licenses and zoning approvals. See Virginia Code 46.2-1600
• Inpatient: means the provision of services, such as food, laundry, housekeeping, and staff to provide health or health-related services, including respite and symptom management, to hospice patients, whether in a hospital, nursing facility, or hospice facility. See Virginia Code 32.1-162.1
• Inspection: means all surveys, inspections, investigations and other procedures necessary for the Department of Health to perform in order to carry out various obligations imposed on the Board or Commissioner by applicable state and federal laws and regulations. See Virginia Code 32.1-123
• Interdisciplinary team: means the patient and the patient's family, the attending physician, and the following hospice personnel: physician, nurse, social worker, and trained volunteer. See Virginia Code 32.1-162.1
• Late model vehicle: means the current-year model of a vehicle and the five preceding model years, or any vehicle whose actual cash value is determined to have been at least $10,000 prior to being damaged. See Virginia Code 46.2-1600
• Lawsuit: A legal action started by a plaintiff against a defendant based on a complaint that the defendant failed to perform a legal duty, resulting in harm to the plaintiff.
• Licensee: means any person who is licensed or is required to be licensed under this chapter. See Virginia Code 46.2-1600
• Medical care facility: means any institution, place, building, or agency, whether or not licensed or required to be licensed by the Board or the Department of Behavioral Health and Developmental Services, whether operated for profit or nonprofit, and whether privately owned or privately operated or owned or operated by a local governmental unit, (i) by or in which health services are furnished, conducted, operated, or offered for the prevention, diagnosis, or treatment of human disease, pain, injury, deformity, or physical condition, whether medical or surgical, of two or more nonrelated persons who are injured or physically sick or have mental illness, or for the care of two or more nonrelated persons requiring or receiving medical, surgical, nursing, acute, chronic, convalescent, or long-term care services, or services for individuals with disabilities, or (ii) which is the recipient of reimbursements from third-party health insurance programs or prepaid medical service plans. See Virginia Code 32.1-3
• Nonrelated: means not related by blood or marriage, ascending or descending or first degree full or half collateral. See Virginia Code 32.1-123
• Nonrepairable certificate: means a document of ownership issued by the Department for any nonrepairable vehicle upon surrender or cancellation of the vehicle's title and registration or salvage certificate. See Virginia Code 46.2-1600
• Nonrepairable vehicle: means any vehicle that has been determined by its insurer or owner to have no value except for use as parts and scrap metal or for which a nonrepairable certificate has been issued or applied for. See Virginia Code 46.2-1600
• Nursing home: means any facility or any identifiable component of any facility licensed pursuant to this article in which the primary function is the provision, on a continuing basis, of nursing services and health-related services for the treatment and inpatient care of two or more nonrelated individuals, including facilities known by varying nomenclature or designation such as convalescent homes, skilled nursing facilities or skilled care facilities, intermediate care facilities, extended care facilities and nursing or nursing care facilities. See Virginia Code 32.1-123
• Peer of the treating health care provider: means a physician or other health care professional who holds a nonrestricted license in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. See Virginia Code 32.1-137.7
• Person: means an individual, corporation, partnership, or association or any other legal entity. See Virginia Code 32.1-3
• Person: includes any partnership, corporation, association or other legal entity, public or private. See Virginia Code 32.1-162.7
• Physician advisor: means a physician licensed to practice medicine in the Commonwealth of Virginia or under a comparable licensing law of a state of the United States who provides medical advice or information to a private review agent or a utilization review entity in connection with its utilization review activities. See Virginia Code 32.1-137.7
• plan: means a written procedure for performing review. See Virginia Code 32.1-137.7
• Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. ^{Source: OCC}
• Private review agent: means a person or entity performing utilization reviews, except that the term shall not include the following entities or employees of any such entity so long as they conduct utilization reviews solely for subscribers, policyholders, members or enrollees:

  1. See Virginia Code 32.1-137.7

• Pro se: A Latin term meaning "on one's own behalf"; in courts, it refers to persons who present their own cases without lawyers.
• Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
• provider: means a licensed health care provider who renders or proposes to render health care services to a covered person. See Virginia Code 32.1-137.7
• Rebuilder: means any person who acquires and repairs, for use on the public highways, two or more salvage vehicles within a 12-month period. See Virginia Code 46.2-1600
• Rebuilt vehicle: means (i) any salvage vehicle that has been repaired for use on the public highways or (ii) any late model vehicle that has been repaired and the estimated cost of repair exceeded 75 percent of its actual cash value, excluding the cost to repair damage to the engine, transmission, or drive axle assembly. See Virginia Code 46.2-1600
• Repairable vehicle: means a late model vehicle that is not a rebuilt vehicle, but is repaired to its pre-loss condition by an insurance company and is not accepted by the owner of said vehicle immediately prior to its acquisition by said insurance company as part of the claims process. See Virginia Code 46.2-1600
• Residence: means the place where the individual or patient makes his home such as his own apartment or house, a relative's home or an assisted living facility, but shall not include a hospital, nursing facility or nursing home or other extended care facility. See Virginia Code 32.1-162.7
• revocation: means that the document or privilege revoked is not subject to renewal or restoration except through reapplication after the expiration of the period of revocation. See Virginia Code 46.2-100
• Salvage certificate: means a document of ownership issued by the Department for any salvage vehicle upon surrender or cancellation of the vehicle's title and registration. See Virginia Code 46.2-1600
• Salvage dealer: means any person who acquires any vehicle for the purpose of reselling any parts thereof or who acquires and sells any salvage vehicle as a unit except as permitted by subdivision B 2 of § Virginia Code 46.2-1600
• Salvage pool: means any person providing a storage service for salvage vehicles or nonrepairable vehicles who either displays the vehicles for resale or solicits bids for the sale of salvage vehicles or nonrepairable vehicles, but this definition shall not apply to an insurance company that stores and displays fewer than 100 salvage vehicles and nonrepairable vehicles in one location; however, any two or more insurance companies who display salvage and nonrepairable vehicles for resale, using the same facilities, shall be considered a salvage pool. See Virginia Code 46.2-1600
• Salvage vehicle: means (i) any late model vehicle that has been (a) acquired by an insurance company as a part of the claims process other than a stolen vehicle or (b) damaged as a result of collision, fire, flood, accident, trespass, or any other occurrence to such an extent that its estimated cost of repair, excluding charges for towing, storage, and temporary replacement/rental vehicle or payment for diminished value compensation, would exceed its actual cash value less its current salvage value; (ii) any recovered stolen vehicle acquired by an insurance company as a part of the claims process, whose estimated cost of repair exceeds 75 percent of its actual cash value; or (iii) any other vehicle that is determined to be a salvage vehicle by its owner or an insurance company by applying for a salvage certificate for the vehicle, provided that such vehicle is not a nonrepairable vehicle. See Virginia Code 46.2-1600
• Scrap metal processor: means any person who acquires one or more whole vehicles to process into scrap for remelting purposes who, from a fixed location, utilizes machinery and equipment for processing and manufacturing ferrous and nonferrous metallic scrap into prepared grades, and whose principal product is metallic scrap. See Virginia Code 46.2-1600
• State Board: means the State Board of Health. See Virginia Code 32.1-3
• Subpoena: A command to a witness to appear and give testimony.
• Subpoena duces tecum: A command to a witness to produce documents.
• Substandard quality of care: means deficiencies in practices of patient care, preservation of patient rights, environmental sanitation, physical plant maintenance, or life safety which, if not corrected, will have a significant harmful effect on patient health and safety. See Virginia Code 32.1-123
• Testify: Answer questions in court.
• Utilization review: means a system for reviewing the necessity, appropriateness and efficiency of hospital, medical or other health care services rendered or proposed to be rendered to a patient or group of patients for the purpose of determining whether such services should be covered or provided by an insurer, health services plan, managed care health insurance plan licensee, or other entity or person. See Virginia Code 32.1-137.7
• Vehicle: means every device in, on or by which any person or property is or may be transported or drawn on a highway, except personal delivery devices and devices moved by human power or used exclusively on stationary rails or tracks. See Virginia Code 46.2-100
• Vehicle removal operator: means any person who acquires a vehicle for the purpose of reselling it to a demolisher, scrap metal processor, or salvage dealer. See Virginia Code 46.2-1600