§1060.12. Definitions
As used in this Subpart, the following definitions apply unless the context indicates
otherwise:
(1)"Consensus statements" means statements developed by an independent,
multidisciplinary panel of experts utilizing a transparent methodology and reporting structure
and with a conflict-of-interest policy that are published in impactful scientific journals. The
statements are aimed at specific, and often times rare, clinical circumstances and based on
the best available evidence for the purpose of optimizing the outcomes of clinical care.
(2)"Health coverage plan" means any hospital, health, or medical expense insurance
policy, hospital or medical service contract, employee welfare benefit plan, contract, or other
agreement with a health maintenance organization or a pr
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§1060.12. Definitions
As used in this Subpart, the following definitions apply unless the context indicates
otherwise:
(1) "Consensus statements" means statements developed by an independent,
multidisciplinary panel of experts utilizing a transparent methodology and reporting structure
and with a conflict-of-interest policy that are published in impactful scientific journals. The
statements are aimed at specific, and often times rare, clinical circumstances and based on
the best available evidence for the purpose of optimizing the outcomes of clinical care.
(2) "Health coverage plan" means any hospital, health, or medical expense insurance
policy, hospital or medical service contract, employee welfare benefit plan, contract, or other
agreement with a health maintenance organization or a preferred provider organization,
health and accident including a group insurance plan or self-insurance plan and the office of
group benefits. "Health coverage plan" does not include a plan providing coverage for
excepted benefits defined in R.S. 22:1061, limited benefit health insurance plans, and
short-term policies that have a term of less than twelve months.
(3) "Health insurance issuer" means an entity subject to the Louisiana Insurance
Code and applicable regulations, or subject to the jurisdiction of the commissioner, that
contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for,
pay for, or reimburse any of the costs of healthcare services, including a sickness and
accident insurance company, a health maintenance organization, a preferred provider
organization or any similar entity, or any other entity providing a plan of health insurance or
health benefits.
(4) "Nationally recognized clinical practice guidelines" means evidence-based
clinical guidelines developed by independent organizations or medical professional societies,
including but not limited to the National Comprehensive Cancer Network, the American
Society of Clinical Oncology, and the American Society of Hematology, utilizing a
transparent methodology and reporting structure and having policies against conflicts of
interest. The guidelines shall establish best practices informed by a systematic review of
evidence, an assessment of the benefits and costs of alternative care options, and
recommendations intended to optimize patient care.
(5) "Positron emission tomography" means an imaging test that uses radioactive
substances to visualize and measure metabolic processes in the body to help reveal how
tissue and organs are functioning. The provisions of this Section shall not apply to non-melanomatous skin cancer.
(6) "Prior authorization" means a determination by a health insurance issuer or
person contracting with a health insurance issuer that healthcare services ordered by the
provider to an individual or an enrollee are medically necessary and appropriate.
(7) "Utilization review" means a set of formal techniques designed to monitor the
use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of,
healthcare services, procedures, or settings. Techniques include but are not limited to
ambulatory review, prior authorization, second opinion, certification, concurrent review, case
management, discharge planning, or retrospective review. "Utilization review" does not
include elective requests for clarification of coverage.