As used in this subchapter:
(1) (A) "Adverse determination" means a decision by a utilization review entity to deny, reduce, or terminate coverage for a healthcare service furnished or proposed to be furnished to a subscriber on the basis that the healthcare service is not medically necessary or is experimental or investigational in nature.
(B) "Adverse determination" does not include a decision to deny, reduce, or terminate coverage for a healthcare service on any basis other than medical necessity or that the healthcare service is experimental or investigational in nature;
(2) "Authorization" means that a utilization review entity has:
(A) Reviewed the information provided concerning a healthcare service furnished or proposed to be furnished;
(B) Found that the requirements for medical necessity and appropriateness of care have been met; and
(C) Determined to pay for the healthcare service according to the provisions of the health benefit plan;
(3) "Clinical criteria" means any written policy, written screening procedures, drug formularies, lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and other criteria or rationale used by the utilization review entity to determine the necessity and appropriateness of a healthcare service;
(4) "Emergency healthcare service" means a healthcare service provided in a fixed facility in the first few hours after an injury or after the onset of an acute medical or obstetric condition that manifests itself by one (1) or more symptoms of such severity, including severe pain, that in the absence of immediate medical care would reasonably be expected to result in:
(A) Serious impairment of bodily function;
(B) Serious dysfunction of or damage to any bodily organ or part; or
(C) Death or threat of death;
(5) "Expedited prior authorization" means prior authorization and notice of that prior authorization for an urgent healthcare service to a subscriber or the subscriber's healthcare provider within one (1) business day after the utilization review entity receives all information needed to complete the review of the requested urgent healthcare service;
(6) "Fail first" means a protocol by a healthcare insurer requiring that a healthcare service preferred by a healthcare insurer shall fail to help a patient before the patient receives coverage for the healthcare service ordered by the patient's healthcare provider;
(7) "Health benefit plan" means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare insurer in this state;
(8) (A) "Healthcare insurer" means an insurance company, health maintenance organization, and a hospital and medical service corporation.
(B) "Healthcare insurer" does not include workers' compensation plans or Medicaid;
(9) "Healthcare provider" means a doctor of medicine, a doctor of osteopathy, or another licensed healthcare professional acting within the professional's licensed scope of practice;
(10) (A) "Healthcare service" means a healthcare procedure, treatment, or service:
(i) Provided by a facility licensed in this state or in the state where the facility is located; or
(ii) Provided by a doctor of medicine, a doctor of osteopathy, or by a healthcare professional within the scope of practice for which the healthcare professional is licensed in this state.
(B) "Healthcare service" includes the provision of pharmaceutical products or services or durable medical equipment;
(11) "Medicaid" means the state-federal medical assistance program established by Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.;
(12) "Medically necessary healthcare service" means a healthcare service that a healthcare provider provides to a patient in a manner that is:
(A) In accordance with generally accepted standards of medical practice;
(B) Clinically appropriate in terms of type, frequency, extent, site, and duration; and
(C) Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other healthcare provider;
(13) "Nonmedical approval" means a decision by a utilization review entity to approve coverage and payment for a healthcare service according to the provisions of the health benefit plan on any basis other than whether the healthcare service is medically necessary or is experimental or investigational in nature;
(14) "Nonmedical denial" means a decision by a utilization review entity to deny, reduce, or terminate coverage for a healthcare service on any basis other than whether the healthcare service is medically necessary or the healthcare service is experimental or investigational in nature;
(15) "Nonmedical review" means the process by which a utilization review entity decides to approve or deny coverage of or payment for a healthcare service before or after it is given on any basis other than whether the healthcare service is medically necessary or the healthcare service is experimental or investigational in nature;
(16) (A) "Prior authorization" means the process by which a utilization review entity determines the medical necessity and medical appropriateness of an otherwise covered healthcare service before the healthcare service is rendered, including without limitation preadmission review, pretreatment review, utilization review, and case management.
(B) "Prior authorization" may include the requirement by a health insurer or a utilization review entity that a subscriber or healthcare provider notify the health insurer or utilization review entity of the subscriber's intent to receive a healthcare service before the healthcare service is provided;
(17) "Self-insured health plan for employees of governmental entity" means a trust established under § 14-54-101 et seq. or § 25-20-104 to provide benefits such as accident and health benefits, death benefits, disability benefits, and disability income benefits;
(18) "Step therapy" means a protocol by a healthcare insurer requiring that a subscriber not be allowed coverage of a prescription drug ordered by the subscriber's healthcare provider until other less expensive drugs have been tried;
(19) (A) "Subscriber" means an individual eligible to receive coverage of healthcare services by a healthcare insurer under a health benefit plan.
(B) "Subscriber" includes a subscriber's legally authorized representative;
(20) "Urgent healthcare service" means a healthcare service for a non-life-threatening condition that, in the opinion of a physician with knowledge of a subscriber's medical condition, requires prompt medical care in order to prevent:
(A) A serious threat to life, limb, or eyesight;
(B) Worsening impairment of a bodily function that threatens the body's ability to regain maximum function;
(C) Worsening dysfunction or damage of any bodily organ or part that threatens the body's ability to recover from the dysfunction or damage; or
(D) Severe pain that cannot be managed without prompt medical care; and
(21) (A) "Utilization review entity" means an individual or entity that performs prior authorization or nonmedical review for at least one (1) of the following:
(i) An employer with employees in this state who are covered under a health benefit plan or health insurance policy;
(ii) An insurer that writes health insurance policies;
(iii) A preferred provider organization or health maintenance organization; or
(iv) Any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to a person treated by a healthcare provider in this state under a policy, plan, or contract.
(B) A health insurer is a utilization review entity if it performs prior authorization.
(C) "Utilization review entity" does not include an insurer of automobile, homeowner, or casualty and commercial liability insurance or the insurer's employees, agents, or contractors.
Section: Previous 23-99-1102 23-99-1103 23-99-1104 23-99-1105 23-99-1106 23-99-1107 23-99-1108 23-99-1109 23-99-1110 23-99-1111 23-99-1112 23-99-1113 23-99-1114 NextLast modified: November 15, 2016