Vol. 35 Iss. 19 - May 13, 2019

Chapter 216

REGISTRAR'S NOTICE: Forms used in administering the regulation have been filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The form is also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, 900 East Main Street, 11th Floor, Richmond, Virginia 23219.

Title of Regulation: 14VAC5-216. Rules Governing Internal Appeal and External Review.

Agency Contact: Kim Naoroz, Principal Insurance Market Examiner, State Corporation Commission, Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218, telephone (804) 371-9913, FAX (804) 371-9944, or email

FORMS (14VAC5-216)

External Review Request Form, Form 216-A (eff. 7/11)

External Review Request Form, Form 216-A (rev 4/2019)

Appointment of Authorized Representative, Form 216-B (eff. 7/2011)

Physician Certification Expedited External Review Request, Form 216-C (eff. 7/2011)

Physician Certification Experimental or Investigational Denials, Form 216-D (eff. 7/2011)

Independent Review Organization Application for Registration, Form 216-E (rev. 7/2014)

Health Carrier External Review Annual Report Form, Form 216-F (eff. 7/2011)

Independent Review Organization External Review Annual Report Form, Form 216-G (eff. 7/2011)

Self-Insured Plan Opt-In to Virginia External Review Process, Form 216-H (eff. 7/2011)

VA.R. Doc. No. R19-5970; Filed April 23, 2019, 12:15 p.m.