For purposes of the Health Carrier External
Review Act:
(1)Adverse determination
means a determination by a health carrier or its designee utilization review
organization that an admission, the availability of care, a continued stay,
or other health 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
therefor denied, reduced, or terminated;
(2)Ambulatory review means the utilization review
of health care services performed or provided in an outpatient setting;
(3)Authorized representative
means:
(a)A person to whom a covered person has given exp
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For purposes of the Health Carrier External
Review Act:
(1) Adverse determination
means a determination by a health carrier or its designee utilization review
organization that an admission, the availability of care, a continued stay,
or other health 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
therefor denied, reduced, or terminated;
(2) Ambulatory review means the utilization review
of health care services performed or provided in an outpatient setting;
(3) Authorized representative
means:
(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; or
(c) A family member of the covered person or the covered
person's treating health care professional only when the covered person is
unable to provide consent;
(4) Benefits or covered benefits means those health
care services to which a covered person is entitled under the terms of a health
benefit plan;
(5)
Best evidence means evidence based on:
(a) Randomized clinical trials;
(b) If randomized clinical
trials are not available, cohort studies or case-control studies;
(c) If the criteria described
in subdivisions (5)(a) and (b) of this section are not available, case-series;
or
(d)
If the criteria described in subdivisions (5)(a), (b), and (c) of this section
are not available, expert opinions;
(6) Case-control study means a retrospective evaluation
of two groups of patients with different outcomes to determine which specific
interventions the patients received;
(7) Case management means a coordinated set of activities
conducted for individual patient management of serious, complicated, protracted,
or other health conditions;
(8) Case-series means an evaluation of a series of
patients with a particular outcome, without the use of a control group;
(9) Certification means
a determination by a health carrier or its designee utilization review organization
that an admission, the availability of care, a continued stay, or other health
care service has been reviewed and, based upon the information provided, satisfies
the health carrier's requirements for medical necessity, appropriateness,
health care setting, level of care, and effectiveness;
(10) 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;
(11) Cohort study means
a prospective evaluation of two groups of patients with only one group of
patients receiving a specific intervention;
(12) Concurrent review means a utilization review
conducted during a patient's hospital stay or course of treatment;
(13) Covered person means
a policyholder, subscriber, enrollee, or other individual participating in
a health benefit plan;
(14)
Director means the Director of Insurance;
(15) Discharge planning means the formal process for
determining, prior to discharge from a facility, the coordination and management
of the care that a patient receives following discharge from a facility;
(16) 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;
(17)
Emergency medical condition means the sudden and, at the time, unexpected
onset of a health condition or illness that requires immediate medical attention
if failure to provide such medical attention would result in a serious impairment
to bodily functions or serious dysfunction of a bodily organ or part or would
place the person's health in serious jeopardy;
(18) Emergency services means health
care items and services furnished or required to evaluate and treat an emergency
medical condition;
(19)
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 an individual patient;
(20) Expert opinion means
a belief or an interpretation by a specialist with experience in a specific
area about the scientific evidence pertaining to a particular service, intervention,
or therapy;
(21)
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;
(22) Final adverse determination
means an adverse determination involving a covered benefit that has been upheld
by a health carrier, or its designee utilization review organization, at the
completion of the health carrier's internal grievance process procedures as
set forth in the Health Carrier Grievance Procedure Act;
(23) 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;
(24) Health care professional means a physician or
other health care practitioner licensed, accredited, or certified to perform
specified health care services consistent with state law;
(25) Health care provider
or provider means a health care professional or a facility;
(26) Health care services
means services for the diagnosis, prevention, treatment, cure, or relief of
a health condition, illness, injury, or disease;
(27) Health carrier means an entity
subject to the insurance laws and regulations of this state, or subject to
the jurisdiction of the director, that contracts or offers to contract to
provide, deliver, arrange for, pay for, or reimburse any of the costs of health
care services, including a sickness and accident insurance company, a health
maintenance organization, a nonprofit hospital and health service corporation,
or any other entity providing a plan of health insurance, health benefits,
or health care services;
(28)
Health information means information or data, whether oral or recorded in
any form or medium, and personal facts or information about events or relationships
that relates to:
(a)
The past, present, or future physical, mental, or behavioral health or condition
of an individual or a member of the individual's family;
(b) The provision of
health care services to an individual; or
(c) Payment for the provision of health care services
to an individual;
(29)
Independent review organization means an entity that conducts independent
external reviews of adverse determinations and final adverse determinations;
(30) Medical or scientific
evidence means evidence found in 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 United States National Library of Medicine
for indexing in Index Medicus, known as Medline, and Elsevier Science Ltd.
for indexing in Excerpta Medica, known as Embase;
(c) Medical journals recognized
by the Secretary of Health and Human Services under section 1861(t)(2) of
the federal Social Security Act;
(d) The following standard reference compendia:
(i) The AHFS Drug Information;
(ii) Drug Facts and Comparisons;
(iii) The American Dental
Association Guide to Dental Therapeutics; and
(iv) The 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:
(i)
The federal Agency for Healthcare Research and Quality of the United States
Department of Health and Human Services;
(ii) The National Institutes of Health;
(iii) The National Cancer
Institute;
(iv)
The National Academy of Sciences;
(v) The Centers for Medicare and Medicaid Services
of the United States Department of Health and Human Services;
(vi) The federal Food
and Drug Administration; and
(vii) Any national board recognized by the National
Institutes of Health for the purpose of evaluating the medical value of health
care services; or
(f)
Any other medical or scientific evidence that is comparable to the sources
listed in subdivisions (30)(a) through (e) of this section;
(31) Prospective review
means a utilization review conducted prior to an admission or a course of
treatment;
(32)
Protected health information means health information:
(a) That identifies an
individual who is the subject of the information; or
(b) With respect to which there
is a reasonable basis to believe that the information could be used to identify
an individual;
(33)
Randomized clinical trial means a controlled, prospective study of patients
that have 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;
(34) Retrospective review means a review of medical
necessity conducted after health care services have been provided to a patient,
but does not include the review of a claim that is limited to an evaluation
of reimbursement levels, veracity of documentation, accuracy of coding, or
adjudication for payment;
(35)
Second opinion means an opportunity or requirement to obtain a clinical evaluation
by a provider other than the one originally making a recommendation for a
proposed health care service to assess the clinical necessity and appropriateness
of the initial proposed health care service;
(36) Utilization review means a
set of formal techniques designed to monitor the use or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of health care services,
procedures, or settings. Techniques may include ambulatory review, prospective
review, second opinion, certification, concurrent review, case management,
discharge planning, or retrospective review; and
(37) Utilization review organization
means an entity that conducts a utilization review, other than a health carrier
performing a review for its own health benefit plans.