Terms Used In Virginia Code > Title 58.1 > Subtitle I > Chapter 1 - General Provisions

• 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
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• 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
• Assessment: as used in this subtitle , shall include an assessment made pursuant to notice by the Department of Taxation and self-assessments made by a taxpayer upon the filing of a return or otherwise not pursuant to notice. See Virginia Code 58.1-1820
• Authorized representative: means (i) a person to whom a covered person has given express written consent to represent the covered person in an external review, (ii) a person authorized by law to provide substituted consent for a covered person, or (iii) a family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent. See Virginia Code 38.2-3556
• 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
• 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
• City: means an independent incorporated community which became a city as provided by law before noon on July 1, 1971, or which has within defined boundaries a population of 5,000 or more and which has become a city as provided by law. See Virginia Code 1-208
• 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.
• Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. See Virginia Code 38.2-3556
• Commission: means the State Corporation Commission. See Virginia Code 38.2-100
• Contract: A legal written agreement that becomes binding when signed.
• Council: means the governing body of a city or town. See Virginia Code 15.2-102
• County: means any existing county or such unit hereafter created. See Virginia Code 15.2-102
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Virginia Code 38.2-3556
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Department: means the Department of Taxation. See Virginia Code 58.1-1
• Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. 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.
• Evidence-based standard: means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients. 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
• Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review entity, at the completion of the health carrier's internal appeal process. See Virginia Code 38.2-3556
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• 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
• in writing: include any representation of words, letters, symbols, numbers, or figures, whether (i) printed or inscribed on a tangible medium or (ii) stored in an electronic or other medium and retrievable in a perceivable form and whether an electronic signature authorized by Virginia Code 1-257
• Includes: means includes, but not limited to. See Virginia Code 1-218
• Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Virginia Code 38.2-3556
• Joint activity: means a governmental function which is carried out by, performed on behalf of, or contracted for two or more localities within a region and includes present and future activities. See Virginia Code 15.2-1307
• 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 all counties, cities and towns within a regional partnership. See Virginia Code 15.2-1307
• 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
• NAIC: means the National Association of Insurance Commissioners. See Virginia Code 38.2-3556
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• 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
• Person: includes any individual, corporation, partnership, association, cooperative, limited liability company, trust, joint venture, government, political subdivision, or any other legal or commercial entity and any successor, representative, agent, agency, or instrumentality thereof. See Virginia Code 1-230
• Personal property: All property that is not real property.
• Process: includes subpoenas, the summons and complaint in a civil action, and process in statutory actions. See Virginia Code 1-237
• provider: means a health care professional or a facility. See Virginia Code 38.2-3556
• Region: means a planning district; however, by agreement of the localities of the planning district, localities which are not part of a planning district may be added to the region if the locality's governing body by vote agrees to become part of the region. See Virginia Code 15.2-1307
• Regional partnership: means an organization composed of government, business, education and civic leaders approved by the local governing bodies of the region to carry out the provisions of this chapter. See Virginia Code 15.2-1307
• reproduction: shall be deemed to include photographs, microphotographs, microfilm, microcard, printouts, optical imaging or other reproductions of electronically stored data, or any other reproduction of an original from a process which forms a durable medium for its recording, storing, and reproducing. See Virginia Code 58.1-106
• 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
• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100
• 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
• Subpoena: A command to a witness to appear and give testimony.
• Subpoena duces tecum: A command to a witness to produce documents.
• Summons: Another word for subpoena used by the criminal justice system.
• Testify: Answer questions in court.
• Town: means any existing town or an incorporated community within one or more counties which became a town before noon, July one, nineteen hundred seventy-one, as provided by law or which has within defined boundaries a population of 1,000 or more and which has become a town as provided by law. See Virginia Code 15.2-102
• 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
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• 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