External review in Virginia: filing with the SCC Bureau of Insurance

Who runs external review in Virginia

Virginia's program sits inside the State Corporation Commission's Bureau of Insurance, in the Life and Health Division. The SCC is a constitutional regulatory body headed by three commissioners rather than a governor's cabinet agency, and external review is a named intake unit there with its own inbox and toll-free line — which matters when you need to reach a person about one specific case.

The governing chapter is Va. Code Title 38.2, Chapter 35.1, and Virginia appears in the state-process column of CCIIO's state-by-state table rather than among the HHS-administered states. Two routes run around the Bureau. An out-of-network payment denial is directed to the federal No Surprises Act external review at externalappeal.cms.gov instead of Virginia's process. And a self-insured ERISA welfare benefit plan, which the chapter otherwise excludes, may voluntarily ask the Commission for a standard external review under Va. Code § 38.2-3557(B).

• Eligible denials go to an independent review organization; the decision binds the carrier, and binds the covered person only to the extent other state or federal remedies do not remain open (§ 38.2-3564).
• Out-of-network payment denials: the Bureau routes those to the federal No Surprises Act external review, not to Chapter 35.1.
• Self-funded ERISA plans can opt in under § 38.2-3557(B) — an invitation few state statutes extend.

120 days — and a practice can start the clock itself

The window is 120 days, measured from receipt of the carrier's notice of your right to an external review. The statute frames it as 120 days after receipt of a notice of adverse determination or final adverse determination together with the notice of external-review rights (§ 38.2-3561(A)), and the same 120 days governs experimental and investigational reviews under § 38.2-3563. Form 216-A prints the number in capitals, which tells you how often it gets missed.

There is no separate, shorter provider window, which is worth knowing if you work denials across several states. Form 216-A's applicant box lists Provider alongside the covered person and an authorized representative, so a treating practice can be the applicant on the full 120 days. Whenever the applicant is not the covered person, Form 216-B — the appointment of an authorized representative — goes in with the request.

How to file with the Bureau

1. 1

   Call before you send anything

   The Bureau asks applicants to phone 1-877-310-6560 first so staff can tell you which companion forms your particular case needs.

2. 2

   Complete Form 216-A

   The External Review Request Form goes to the regulator, not the carrier: Bureau of Insurance — External Review, P.O. Box 1157, Richmond, VA 23218; fax (804) 371-9915; or [email protected].

3. 3

   Add the companion form the case calls for

   216-B when anyone other than the covered person is filing; 216-C for the physician certification on an expedited review; 216-D for the physician certification on an experimental or investigational denial.

4. 4

   Keep the medical records out of the first envelope

   Form 216-A instructs applicants not to attach records. If the request clears eligibility, the Bureau writes to say where and when to send material, and you then have five business days to get it to the IRO.

The carrier screens eligibility; the Commission picks the reviewer

Those two decisions sit with different parties in Virginia, and the split is worth understanding before you file. Once the Bureau forwards the request, the health plan performs a preliminary eligibility review within five business days (§ 38.2-3561(B)); if the plan calls the request ineligible, that determination can be appealed back to the Bureau. After eligibility clears, § 38.2-3561(D) gives the Commission one business day to assign the IRO, and § 38.2-3566(F) requires that assignment to be made on a random basis, taking into account the nature of the health care service at issue. The carrier has no say in the choice, and the Bureau mails the requester a letter naming the assigned IRO and the schedule.

• Standard review: written decision within 45 days of receipt of the request (§ 38.2-3561(I)).
• Expedited medical necessity: no more than 72 hours after an eligible expedited request, with written confirmation within 48 hours if the decision is given orally (§ 38.2-3562).
• Experimental or investigational: the Bureau states six business days on the expedited track; a standard decision is due within 20 days after all clinical reviewer opinions are received (§ 38.2-3563).
• Expedited review may be requested before the carrier's internal appeals are exhausted for a cancer-treatment denial — no Form 216-C needed — or on a final adverse determination for emergency services while the patient is still admitted.
• Expedited review is unavailable once the service has already been provided, and no additional material may be submitted in an expedited case.
• No fee. § 38.2-3569 puts the IRO's cost on the carrier the request is filed against, and 14VAC5-216-120 makes a carrier's failure to pay the IRO on time a violation.

What Virginia's published numbers show

Outcome figures surface inside the Bureau's annual report to the General Assembly under § 38.2-3412.1 G. The edition dated 11/01/2024, drawing on 2023 carrier survey data, counts 217 external reviews performed and 217 closed. Medical and surgical cases accounted for 205 of them: 104 upheld, one partially upheld, 100 overturned. Mental health added nine (four upheld, five overturned), substance use disorder three (two upheld, one overturned).

That works out to 106 of 217 denials overturned, roughly 49%, and 100 of 205 on the medical and surgical side. The previous published year — 2021 data, in the November 2022 report — ran 194 reviews with 76 overturned, about 39%. The rate moved materially in one direction over that span.

The Managed Care Ombudsman — free, and it takes provider questions

Virginia created an Office of the Managed Care Ombudsman by statute (Va. Code § 38.2-5904) on July 1, 1999, and placed it in the same Bureau. The help costs nothing, and its published remit includes answering questions from health care providers, not consumers only — a line most state consumer-assistance offices don't draw. It also helps consumers build and file the internal appeal that must be exhausted before external review. Contact: [email protected], 1-877-310-6560 option 3, fax 804-371-9944.

Its report to the General Assembly dated 12/01/2025, covering 11/01/2024 through 10/31/2025, gives the scale: 207 consumers assisted with formal appeals (208 the prior year), 383 inquiries, up 6%, and $386,798 in direct cost savings or cost avoidance won at the internal-appeal stage alone, up 3% from $377,136 — across 84 licensed MCHIPs.

For Virginia providers and billers

Prior-authorization law here is mid-change, and part of it is already usable. HB 481 (2026), Chapter 925 of the Acts of Assembly, was approved 04/13/2026 and takes effect 07/01/2026: a carrier may not issue an adverse determination on a prior-authorization request unless a licensed physician reviewed and approved it. For drugs, a licensed pharmacist may stand in when no physician is available; for mental health services, a licensed mental health provider; for dental, a licensed dentist. A denial that came back with no clinician behind it is worth naming in the appeal.

Drug prior authorization already runs on clocks under § 38.2-3407.15:2: 24 hours on an urgent request, weekends included, and two business days on a fully completed standard request or on supplementation. Another carrier's prior authorization must be honored for at least the first 90 days of new coverage, an approval carries across a non-opioid dosage change and across plan changes within the same carrier, and at least one medication-assisted-treatment drug must be available with no PA at all. Step-therapy overrides (§ 38.2-3407.9:05) must be granted on contraindication, expected ineffectiveness, prior discontinuation for lack of efficacy or an adverse event, or a current positive therapeutic outcome, with a carrier response inside 72 hours — 24 hours under exigent circumstances.

The broader medical-services statute, § 38.2-3407.15:8 from HB 2099 / SB 1215 (2025), is enacted but not yet in force; it starts 01/01/2027. It sets 72 hours on expedited requests and seven calendar days on standard ones, requires any request for supplementation to be itemized specifically, and bars a carrier from revoking, limiting, conditioning, modifying, or restricting an approved PA for services already scheduled or provided except on a provider-requested change, fraud or misrepresentation, or action by a federal regulator or the manufacturer. It also requires a central public list of the services and codes that need PA, with 30 days' notice of changes — and a carrier that fails to post cannot deny the claim for lack of prior authorization.

Two things Virginia does not have: gold-carding, and any disclosure rule for AI in utilization management. SB 500 (2026), which would have exempted high-approval-rate providers from PA on routine services and tightened the clocks to 24 hours and five days, was passed by indefinitely in Senate Commerce and Labor on 01/26/2026, 9-Y 6-N. SB 586 (2026), which would have required carriers to disclose AI use to the Bureau and to notify enrollees and providers when AI produced an adverse determination, passed the Senate 23-16 and was continued to 2027 in House Communications, Technology and Innovation on 02/23/2026.

Ask for a peer and the reconsideration becomes an appeal

Virginia gives the treating provider a lever that changes the shape of the process. Under Va. Code 32.1-137.14, a determination on reconsideration must be made by a physician advisor, a peer of the treating provider, or a panel including at least one of them, and must be rendered in writing within ten working days.

The unusual part follows. If the treating provider asks at any point during the reconsideration that the adverse determination be reviewed by a peer, the reconsideration is vacated and treated as an appeal — all documentation carries across, and nothing further is required of the provider to perfect it. Va. Code 32.1-137.7 defines the peer: a provider holding a nonrestricted license and in the same or a similar specialty as typically manages the condition.