§ 31-3875.01 — Definitions.

District of Columbia § 31-3875.01

• Jurisdiction: District of Columbia
• Title 31: Insurance and Securities.
• Ch. 38F: Prior Authorization by a Utilization Review Entity.

Text

(a) For purposes of this chapter , the term:

(1) "Adverse determination" means a decision by a utilization review entity that the health care services furnished or proposed to be furnished to an enrollee is denied, reduced, or terminated as being not medically necessary or experimental or investigational.

(2) "Approval" means a determination by a utilization review entity that a covered health care service has been reviewed and, based on the information provided, satisfies the utilization review entity's requirements for medical necessity and medical appropriateness.

(3) "Emergency health care service" means a health care service that is provided in an emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to place the patient's health in serious jeopardy or to cause serious impairment to bodily function or serious dysfunction of any bodily organ or part.

(4) "Enrollee" means an individual eligible to receive health care benefits by a health insurer pursuant to a health plan or other health insurance coverage.

(5) Not Funded.

(6) "Medication assisted treatment" means the use of medications to provide a comprehensive approach to the treatment of substance use disorders.

(7) "Prior authorization" means the process by which a utilization review entity determines the medical necessity or medical appropriateness of covered health care services prior to the rendering of such services, including any notification that an enrollee or health care provider is required to provide to the health insurer or utilization review entity prior to the provision of a health care service.

(8) "Representative" means the enrollee's legally authorized representative.

(9) "Urgent health care service" means:

(A) A health care service that, in the opinion of a physician with knowledge of the enrollee's medical condition, if not receiving an expedited approval:

(i) Could seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; or

(ii) Could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the prior authorization review; or

(B) Medication assisted treatment.

(10) "Utilization review entity" means an individual or entity that performs prior authorization review for:

(A) A health insurer as that term is defined in § 4-631 ;

(B) A preferred provider organization or health maintenance organization as those terms are described in § 1-621.05(2) and (3) ;

(C) Not Funded.

(D) Not Funded.

(E) Any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, prescription drug, or other health benefits to a person treated by a health care provider in the District under a policy, plan, or contract that is regulated by the District.