As used in this chapter, unless the context otherwise requires:
1.
a.“Adverse determination” means a determination by a health carrier that an
admission, availability of care, continued stay, or other health care service, other than
a dental care service, that is a covered benefit has been reviewed and, based upon the
information provided, does not meet the health carrier’s requirements for medical necessity,
appropriateness, health care setting, level of care, or effectiveness, and the requested service
or payment for the service is therefore denied, reduced, or terminated.
b.For the purposes of denial of a dental care service, “adverse determination” means a
determination by a health carrier that a dental care service that is a covered benefit has
been reviewed and, based upon the info
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As used in this chapter, unless the context otherwise requires:
1. a. “Adverse determination” means a determination by a health carrier that an
admission, availability of care, continued stay, or other health care service, other than
a dental care service, that is a covered benefit has been reviewed and, based upon the
information provided, does not meet the health carrier’s requirements for medical necessity,
appropriateness, health care setting, level of care, or effectiveness, and the requested service
or payment for the service is therefore denied, reduced, or terminated.
b. For the purposes of denial of a dental care service, “adverse determination” means a
determination by a health carrier that a dental care service that is a covered benefit has
been reviewed and, based upon the information provided, does not meet the health carrier’s
requirements for medical necessity, and the requested service or payment for the service is
therefore denied, reduced, or terminated in whole or in part.
c. “Adversedetermination” does not include a denial of coverage for a service or treatment
specifically listed in plan or evidence of coverage documents as excluded from coverage.
2. “Authorized representative” means any of the following:
a. A person to whom a covered person has given express written consent to represent the
covered person in an external review.
b. A person authorized by law to provide substituted consent for a covered person.
c. A family member of the covered person when the covered person is unable to provide
consent.
§514J.102, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 2
d. The covered person’s treating health care professional when the covered person is
unable to provide consent.
3. “Best evidence” means evidence based on randomized clinical trials. If randomized
clinical trials are not available, “best evidence” means evidence based on cohort studies or
case-control studies. If randomized clinical trials, cohort studies, or case-control studies are
not available, “best evidence” means evidence based on case-series studies. If none of these
are available, “best evidence” means evidence based on expert opinion.
4. “Case-control study” means a retrospective evaluation of two groups of patients with
different outcomes to determine which specific interventions the patients received.
5. “Case-series study” means an evaluation of a series of patients with a particular
outcome, without the use of a control group.
6. “Certification” means a determination by a health carrier that an admission, availability
of care, continued stay, or other health care service has been reviewed and, based on the
information provided, satisfies the health carrier’s requirements for medical necessity,
appropriateness, health care setting, level of care, and effectiveness.
7. “Clinical review criteria” means the written screening procedures, decision abstracts,
clinical protocols, and practice guidelines used by a health carrier to determine the necessity
and appropriateness of health care services.
8. “Cohort study” means a prospective evaluation of two groups of patients with only one
group of patients receiving a specific intervention.
9. “Commissioner” means the commissioner of insurance.
10. “Covered benefits” or “benefits” means those health care services to which a covered
person is entitled under the terms of a health benefit plan.
11. “Covered person” means a policyholder, subscriber, enrollee, or other individual
participating in a health benefit plan.
12. “Dental care services” means diagnostic, preventive, maintenance, and therapeutic
dental care that is provided in accordance with chapter 153.
13. “Disclose” means to release, transfer, or otherwise divulge protected health
information to any person other than the individual who is the subject of the protected
health information.
14. “Emergency medical condition” means the sudden and, at the time, unexpected onset
of a health condition or illness that requires immediate medical attention, where failure to
provide medical attention would result in a serious impairment to bodily functions, serious
dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.
15. “Emergency services” means health care items and services furnished or required to
evaluate and treat an emergency medical condition.
16. “Evidence-based standard” means the conscientious, explicit, and judicious use of
the current best evidence based on the overall systematic review of the research in making
decisions about the care of individual patients.
17. “Expert opinion” means a belief or an interpretation by specialists with experience in
a specific area about the scientific evidence pertaining to a particular service, intervention,
or therapy.
18. “Facility” means an institution providing health care services or a health care setting,
including but not limited to hospitals and other licensed inpatient centers, ambulatory
surgical or treatment centers, skilled nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health
settings.
19. “Final adverse determination” means an adverse determination involving a covered
benefit that has been upheld by a health carrier at the completion of the health carrier’s
internal grievance process.
20. “Health benefit plan” means a policy, contract, certificate, or agreement offered or
issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services.
21. “Health care professional” means a physician or other health care practitioner
licensed, accredited, registered, or certified to perform specified health care services
consistent with state law.
3 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.102
22. “Health care provider” or “provider” means a health care professional or a facility.
23. “Health care services” means services for the diagnosis, prevention, treatment, cure,
orreliefofahealthcondition, illness, injury, ordisease. “Healthcareservices”includesdental
care services.
24. “Health carrier” means an entity subject to the insurance laws and regulations of this
state, or subject to the jurisdiction of the commissioner, including an insurance company
offering sickness and accident plans, a health maintenance organization, a nonprofit health
service corporation, a plan established pursuant to chapter 509A for public employees, or any
other entity providing a plan of health insurance, health care benefits, or health care services.
25. “Healthinformation”meansinformationordata, whetheroralorrecordedinanyform
ormedium, andpersonalfactsorinformationabouteventsorrelationshipsthatrelatestoany
of the following:
a. The past, present, or future physical, mental, or behavioral health or condition of a
covered person or a member of the covered person’s family.
b. The provision of health care services to a covered person.
c. Payment to a health care provider for the provision of health care services to a covered
person.
26. “Independent review organization” means an entity that conducts independent
external reviews of adverse determinations and final adverse determinations.
27. “Medical or scientific evidence” means evidence found in any of the following sources:
a. Peer-reviewed scientific studies published in or accepted for publication by medical
journals that meet nationally recognized requirements for scientific manuscripts and that
submit most of their published articles for review by experts who are not part of the editorial
staff.
b. Peer-reviewed medical literature, including literature relating to therapies reviewed
and approved by a qualified institutional review board, biomedical compendia, and other
medical literature that meet the criteria of the national institutes of health’s national library
of medicine for indexing in index medicus or medline, or of elsevier science ltd. for indexing
in excerpta medicus or embase.
c. Medical journals recognized by the United States secretary of health and human
services under section 1861(t)(2) of the federal Social Security Act.
d. The following standard reference compendia:
(1) American hospital formulary service drug information.
(2) Drug facts and comparisons.
(3) American dental association accepted dental therapeutics.
(4) United States pharmacopoeia drug information.
e. Findings, studies, or research conducted by or under the auspices of federal
government agencies and nationally recognized federal research institutes, including any
of the following:
(1) Federal agency for health care research and quality.
(2) National institutes of health.
(3) National cancer institute.
(4) National academy of sciences.
(5) Centers for Medicare and Medicaid services.
(6) Federal food and drug administration.
(7) Any national board recognized by the national institutes of health for the purpose of
evaluating the medical value of health care services.
f. Any other medical or scientific evidence that is comparable to the sources listed in
paragraphs “a” through “e”.
28. “NAIC” means the national association of insurance commissioners.
29. “Person” means an individual, a corporation, a partnership, an association, a joint
venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or
any combination of the foregoing.
30. “Protected health information” means health information that meets either of the
following descriptions:
§514J.102, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 4
a. Health information that identifies a covered person who is the subject of the
information.
b. Health information with respect to which there is a reasonable basis to believe that the
information could be used to identify a covered person.
31. “Randomizedclinicaltrial”meansacontrolled, prospectivestudyofpatientsthathave
been randomized into an experimental group and a control group at the beginning of the
study with only the experimental group of patients receiving a specific intervention, which
includes study of the groups for variables and anticipated outcomes over time.