§ 27-18.9-2. Definitions.
As used in this chapter, the following terms are defined as follows:
(1) "Adverse benefit determination� means a decision not to authorize a healthcare service,
including a denial, reduction, or termination of, or a failure to provide or make
a payment, in whole or in part, for a benefit. A decision by a utilization review
agent to authorize a healthcare service in an alternative setting, a modified extension
of stay, or an alternative treatment shall not constitute an adverse determination
if the review agent and provider are in agreement regarding the decision. Adverse
benefit determinations include:
(i) "Administrative adverse benefit determinations,� meaning any adverse benefit determination
that does not require the use of medical judgment or clinical criteria such as a determination
of an individual's eligibility to participate in coverage, a determination that a
benefit is not a covered benefit, or any rescission of coverage; and
(ii) "Non-administrative adverse benefit determinations,� meaning any adverse benefit determination
that requires or involves the use of medical judgement or clinical criteria to determine
whether the service being reviewed is medically necessary and/or appropriate. This
includes the denial of treatments determined to be experimental or investigational,
and any denial of coverage of a prescription drug because that drug is not on the
healthcare entity's formulary.
(2) "Appeal� or "internal appeal� means a subsequent review of an adverse benefit determination
upon request by a claimant to include the beneficiary or provider to reconsider all
or part of the original adverse benefit determination.
(3) "Authorization� means a review by a review agent, performed according to this chapter,
concluding that the allocation of healthcare services ordered by a provider, given
or proposed to be given to a beneficiary, was approved or authorized.
(4) "Authorized representative� means an individual acting on behalf of the beneficiary
and shall include: the ordering provider; any individual to whom the beneficiary has
given express written consent to act on the beneficiary's behalf; a person authorized
by law to provide substituted consent for the beneficiary; and, when the beneficiary
is unable to provide consent, a family member of the beneficiary.
(5) "Beneficiary� means a policy-holder subscriber, enrollee, or other individual participating
in a health benefit plan.
(6) "Benefit determination� means a decision to approve or deny a request to provide or
make payment for a healthcare service or treatment.
(7) "Certificate� means a certificate granted by the commissioner to a review agent meeting
the requirements of this chapter.
(8) "Claim� means a request for plan benefit(s) made by a claimant in accordance with
the healthcare entity's reasonable procedures for filing benefit claims. This shall
include pre-service, concurrent, and post-service claims.
(9) "Claimant� means a healthcare entity participant, beneficiary, and/or authorized representative
who makes a request for plan benefit(s).
(10) "Commissioner� means the health insurance commissioner.
(11) "Complaint� means an oral or written expression of dissatisfaction by a beneficiary,
authorized representative, or a provider. The appeal of an adverse benefit determination
is not considered a complaint.
(12) "Concurrent assessment� means an assessment of healthcare services conducted during
a beneficiary's hospital stay, course of treatment or services over a period of time,
or for the number of treatments. If the medical problem is ongoing, this assessment
may include the review of services after they have been rendered and billed.
(13) "Concurrent claim� means a request for a plan benefit(s) by a claimant that is for
an ongoing course of treatment or services over a period of time or for the number
of treatments.
(14) "Delegate� means a person or entity authorized pursuant to a delegation of authority
or re-delegation of authority, by a healthcare entity or network plan to perform one
or more of the functions and responsibilities of a healthcare entity and/or network
plan set forth in this chapter or regulations or guidance promulgated thereunder.
(15) "Emergency services� or "emergent services� means those resources provided in the
event of the sudden onset of a medical, behavioral health, or other health condition
that the absence of immediate medical attention could reasonably be expected, by a
prudent layperson, to result in placing the patient's health in serious jeopardy,
serious impairment to bodily or mental functions, or serious dysfunction of any bodily
organ or part.
(16) "External review� means a review of a non-administrative adverse benefit determination
(including final internal adverse benefit determination) conducted pursuant to an
applicable external review process performed by an independent review organization.
(17) "External review decision� means a determination by an independent review organization
at the conclusion of the external review.
(18) "Final internal adverse benefit determination� means an adverse benefit determination
that has been upheld by a plan or issuer at the completion of the internal appeals
process or when the internal appeals process has been deemed exhausted as defined
in § 27-18.9-7(b)(1).
(19) "Health benefit plan� or "health plan� means a policy, contract, certificate, or agreement
entered into, offered, or issued by a healthcare entity to provide, deliver, arrange
for, pay for, or reimburse any of the costs of healthcare services.
(20) "Healthcare entity� means an insurance company licensed, or required to be licensed,
by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner
or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, 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,
without limitation: a for-profit or nonprofit hospital, medical, or dental service
corporation or plan, a health maintenance organization, a health insurance company,
or any other entity providing a plan of health insurance, accident and sickness insurance,
health benefits, or healthcare services.
(21) "Healthcare services� means and includes, but is not limited to: an admission, diagnostic
procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or
filling of formulary or non-formulary medications, and any other medical, behavioral,
dental, vision care services, activities, or supplies that are covered by the beneficiary's
health benefit plan.
(22) "Independent review organization� or "IRO� means an entity that conducts independent
external reviews of adverse benefit determinations or final internal adverse benefit
determinations.
(23) "Insurerâ€�, for the purposes of § 27-18.9-16, means all insurance companies licensed to do business in Rhode Island, including
those subject to chapter 1 of this title, a foreign insurance company licensed to do business in Rhode Island and subject
to chapter 2 of this title, a health insurance carrier subject and organized pursuant to chapter 18 of this title, a nonprofit hospital service corporation subject and organized pursuant to chapter 19 of this title, a nonprofit medical services corporation subject and organized pursuant to chapter 20 of this title, and a qualified health maintenance organization subject and organized pursuant to
chapter 41 of this title.
(24) "Network� means the group or groups of participating providers providing healthcare
services under a network plan.
(25) "Network plan� means a health benefit plan or health plan that either requires a beneficiary
to use, or creates incentives, including financial incentives, for a beneficiary to
use the providers managed, owned, under contract with, or employed by the healthcare
entity.
(26) "Office� means the office of the health insurance commissioner.
(27) "Pre-service claim� means the request for a plan benefit(s) by a claimant prior to
a service being rendered and is not considered a concurrent claim.
(28) "Primary care providerâ€� or "PCPâ€�, for the purposes of § 27-18.9-16, means a provider within the practice type of family medicine, geriatric medicine,
internal medicine, obstetrics and gynecology, or pediatrics, with the following professional
credentials: a doctor of medicine or doctor of osteopathic medicine, a nurse practitioner,
or a physician assistant, and who is credentialed with the insurer as a primary care
provider.
(29) "Prior authorizationâ€�, for the purposes of § 27-18.9-16, means the pre-service assessment for purposes of utilization review that a PCP is
required by an insurer to undergo before a covered healthcare service is approved
for a patient.
(30) "Professional provider� means an individual provider or healthcare professional licensed,
accredited, or certified to perform specified healthcare services consistent with
state law and who provides healthcare services and is not part of a separate facility
or institutional contract.
(31) "Prospective assessment� or "pre-service assessment� means an assessment of healthcare
services prior to services being rendered.
(32) "Provider� means a physician, hospital, professional provider, pharmacy, laboratory,
dental, medical, or behavioral health provider or other state-licensed or other state-recognized
provider of health care or behavioral health services or supplies.
(33) "Retrospective assessment� or "post-service assessment� means an assessment of healthcare
services that have been rendered. This shall not include reviews conducted when the
review agency has been obtaining ongoing information.
(34) "Retrospective claim� or "post-service claim� means any claim for a health plan benefit
that is not a pre-service or concurrent claim.
(35) "Review agent� means a person or healthcare entity performing benefit determination
reviews that is either employed by, affiliated with, under contract with, or acting
on behalf of a healthcare entity.
(36) "Same or similar specialty� means a practitioner who has the appropriate training
and experience that is the same or similar as the attending provider in addition to
experience in treating the same problems to include any potential complications as
those under review.
(37) "Therapeutic interchange� means the interchange or substitution of a drug with a dissimilar
chemical structure within the same therapeutic or pharmacological class that can be
expected to have similar outcomes and similar adverse reaction profiles when given
in equivalent doses, in accordance with protocols approved by the president of the
medical staff or medical director and the director of pharmacy.
(38) "Tiered network� means a network that identifies and groups some or all types of providers
into specific groups to which different provider reimbursement, beneficiary cost sharing,
or provider access requirements, or any combination thereof, apply for the same services.
(39) "Urgent healthcare services� includes those resources necessary to treat a symptomatic
medical, mental health, substance use, or other healthcare condition that a prudent
layperson, acting reasonably, would believe necessitates treatment within a twenty-four-hour
(24) period of the onset of such a condition in order that the patient's health status
not decline as a consequence. This does not include those conditions considered to
be emergent healthcare services as defined in this section.
(40) "Utilization review� means the prospective, concurrent, or retrospective assessment
of the medical necessity and/or appropriateness of the allocation of healthcare services
of a provider, given or proposed to be given, to a beneficiary. Utilization review
does not include:
(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of
a licensed inpatient healthcare facility; or
(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19.1 of title 5, and practicing in a pharmacy operating as part of a licensed inpatient healthcare
facility, in the interpretation, evaluation, and implementation of medical orders,
including assessments and/or comparisons involving formularies and medical orders.
(41) "Utilization review plan� means a description of the standards governing utilization
review activities performed by a review agent.