# 14 Va. Admin. Code § 5-216-10: 14VAC5-216-10. Scope and purpose

> Virginia · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_10

## Section

- **Citation:** 14 Va. Admin. Code § 5-216-10
- **Heading:** 14VAC5-216-10. Scope and purpose
- **Jurisdiction:** Virginia
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Virginia Administrative Code / Title 14 Insurance / Agency 5 State Corporation Commission, Bureau of Insurance / Chapter 216 / 14VAC5-216-10

## Text

A. This chapter shall apply to all health carriers, except that the provisions of this chapter shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage; credit; disability income; hospital indemnity; long-term care; dental, vision care, or any other limited supplemental benefit or to a Medicare supplement policy of insurance; coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program; self-insured plans except that a self-insured employee welfare benefit plan may elect to use the state external review process; any coverage issued under Chapter 55 of Title 10 of the U.S. Code (TRICARE), and any coverage issued as supplemental to that coverage; any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance; and automobile medical payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group or individual basis.
B. The purpose of this chapter is to set forth rules to carry out the provisions of Chapter 35.1 (§ 38.2-3556 et seq.) of Title 38.2 of the Code of Virginia as well as federal law to provide a health carrier with guidelines to assist with establishing a procedure for an internal appeals process under which there will be a full and fair review of any adverse benefit determination. This chapter also sets forth requirements for the external review process.
C. This chapter shall apply to any adverse benefit determination made on or after July 1, 2011, by any health carrier for a grandfathered or non-grandfathered health benefit plan, as defined by the PPACA.
D. This chapter also sets forth requirements for an exception request for plan years beginning on or after January 1, 2016.

## Nearby sections

- [14 Va. Admin. Code § 5-216-10 14VAC5-216-10. Scope and purpose](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_10.md)
- [14 Va. Admin. Code § 5-216-20 14VAC5-216-20. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_20.md)
- [14 Va. Admin. Code § 5-216-30 14VAC5-216-30. General requirements](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_30.md)
- [14 Va. Admin. Code § 5-216-40 14VAC5-216-40. Minimum appeal requirements](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_40.md)
- [14 Va. Admin. Code § 5-216-45 14VAC5-216-45. Exhaustion](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_45.md)
- [14 Va. Admin. Code § 5-216-50 14VAC5-216-50. Urgent care appeals](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_50.md)
- [14 Va. Admin. Code § 5-216-60 14VAC5-216-60. Concurrent review decisions](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_60.md)
- [14 Va. Admin. Code § 5-216-65 14VAC5-216-65. Exception request for prescription drugs](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_65.md)
- [14 Va. Admin. Code § 5-216-70 14VAC5-216-70. Notification requirements](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_70.md)
- [14 Va. Admin. Code § 5-216-80 14VAC5-216-80. Incomplete or ineligible determinations](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_80.md)
- [14 Va. Admin. Code § 5-216-90 14VAC5-216-90. Expedited external review](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_90.md)
- [14 Va. Admin. Code § 5-216-100 14VAC5-216-100. Qualifications for independent review organizations](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_100.md)
- [14 Va. Admin. Code § 5-216-110 14VAC5-216-110. External review reporting requirements](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_110.md)
- [14 Va. Admin. Code § 5-216-120 14VAC5-216-120. Funding of external review](https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_120.md)

---

Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_VA_ADC_14_5_216_10. Check the current official text before relying on it. Not legal advice.