12VAC5-405-70: Minimum qualifications of staff

A. The staff of a private review agent responsible for making utilization review decisions (including nonadverse decisions), as a minimum, shall have qualifications equivalent to or exceeding those of Accredited Record Technicians (ARTs) as awarded by the American Medical Record Association. The staff of a private review agent who are responsible for making utilization review decisions and who are required to be licensed to practice their health care profession shall be licensed by a jurisdiction of the United States.

B. The private review agent shall have available the services of a sufficient number of medical records technicians, licensed practical nurses, registered nurses, or other similarly qualified professionals, supported and supervised by appropriate licensed physicians, to carry out its utilization review activities. The staff shall include nonphysician providers, as appropriate, and physicians in appropriate specialty areas. The physician staff shall include physicians who are board certified or board eligible.