For the purposes of this chapter, the term
(1) “Adverse benefit determination” means a denial, reduction, limitation, termination, failure to make a payment for a benefit, or a delay of a benefit to a member, regarding determinations about:
(A) The medical necessity, appropriateness, or level of care, or health care setting;
(B) Whether a benefit is experimental or investigational;
(C) A decision to rescind coverage;
(D) A member’s eligibility to participate in a plan;
(E) Whether a wellness incentive has been properly applied; or
(F) Whether the member was given a reasonable alternative standard for satisfying a wellness plan when required.
(1A) “Appeal” means a written request by a member or a member representative for a review of an adverse benefit determination.
(1B) “Director” means the Director of the Department of Health Care Finance.
(2) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:
(A) Placing the health or mental health of the individual in serious jeopardy;
(B) Serious impairment to bodily functions or mental or emotional functions;
(C) Serious dysfunction of any bodily organ or part or mental or emotional functions; or
(D) With respect to a pregnant woman, placing the health of the woman or her unborn child in serious jeopardy.
(3) “Grievance” means a written request by a member or a member representative for review of a decision of an insurer to deny, reduce, limit, terminate, or delay a benefit to a member, including regarding:
(A) A determination about the medical necessity, appropriateness, or level of care, health-care setting, or effectiveness of a treatment;
(B) A determination as to whether treatment is experimental;
(C) An insurer’s decision to rescind coverage;
(D) The failure to provide or make payment that is based on a determination of a member’s eligibility to participate in a plan;
(E) Whether a wellness incentive has been properly applied; and
(F) Whether the member was given a reasonable alternative standard for satisfying a wellness plan when required.
(4) “Grievance decision” means a determination accepting or denying the basis or requested remedy of the grievance.
(5) “Health benefits plan” means a group or individual insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar group arrangement provided by an insurer or subcontracting facility of an insurer for the purpose of providing, paying for, or reimbursing expenses for health related services. “Health benefits plan” does not include disability income or accident only insurance.
(6) “Health care services” means items or services provided under the supervision of a physician or other person trained or licensed to render health care necessary for the prevention, care, diagnosis, or treatment of human disease, pain, injury, deformity or other physical or mental condition including the following: pre-admission, outpatient, inpatient, and post-discharge care; home care; physician’s care; nursing care; medical care provided by interns or residents in training; other paramedical care; ambulance service and care; bed and board; drugs; supplies; appliances; equipment; laboratory services; any form of diagnostic imaging or therapeutic radiological services; and services mandated under Chapter 31 of Title 31 .
(7) “Independent review organization” means an impartial, certified health entity engaged by the Director to review any adverse grievance decision by an insurer, including an insurer’s decision to deny, terminate, or limit covered health care services.
(8) “Insurer” means any individual, partnership, corporation, association, fraternal benefit association, hospital and medical services corporation, health maintenance organization, or other business entity that issues, amends, or renews group or individual health insurance policies or contracts, including health maintenance organization membership contracts in the District.
(9) “Member” means an individual who is enrolled in a health benefits plan.
(10) “Member representative” means a:
(A) Person acting on behalf of a member with the member’s consent;
(B) Person authorized by law to provide substituted consent for a covered person;
(C) Family member of the covered person;
(D) Covered person’s treating health care professional when the covered person is unable to provide consent; or
(E) In the case of a request regarding an emergency or urgent medical condition, a health-care professional with knowledge of the covered person’s medical condition.
(10A) “Rescission” means a cancellation or discontinuance of coverage that has a retroactive effect (which is prohibited except in cases of fraud or intentional misrepresentation of material fact).
(11) “Urgent medical condition” means a condition with respect to which the application of time periods for making non-urgent claims decisions could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain his or her maximum possible function, or, in the opinion of a physician with knowledge of the covered person’s medical condition, would subject the covered person to severe pain that could not be adequately managed without the health care services being requested.