As used in this article, the term:
(1) "Department" means the Department of Community Health established under Chapter 2 of Title 31.
(2) "Eligible enrollee" means a person who:
(A) Is an enrollee or an eligible dependent of an enrollee of a managed care plan or was an enrollee or an eligible dependent of an enrollee of such plan at the time of the request for treatment;
(B) Seeks a treatment which reasonably appears to be a covered service or benefit under the enrollee's evidence of coverage; provided, however, that this subparagraph shall not apply if the notice from a managed care plan of the outcome of the grievance procedure was that a treatment is experimental; and
(C) Is not a Medicaid care management member.
(3) "Grievance procedure" means the grievance procedure established pursuant to Code Section 33-20A-5.
(4) "Independent review organization" means any organization certified as such by the department under Code Section 33-20A-39.
(5) "Medicaid care management member" means a recipient of medical assistance, as that term is defined in paragraph (7) of Code Section 49-4-141, and shall also include a child receiving health care benefits pursuant to Article 13 of Chapter 5 of Title 49.
(6) "Medical and scientific evidence" means:
(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 literature, 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, Excerpta Medicus (EMBASE), Medline, and MEDLARS data base or Health Services Technology Assessment Research (HSTAR);
(C) Medical journals recognized by the United States secretary of health and human services, under Section 1861(t)(2) of the Social Security Act;
(D) The following standard reference compendia: the American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information; or
(E) Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the Federal Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, the Centers for Medicare and Medicaid Services, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services.
(7) "Medical necessity," "medically necessary care," or "medically necessary and appropriate" means care based upon generally accepted medical practices in light of conditions at the time of treatment which is:
(A) Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the eligible enrollee's condition;
(B) Compatible with the standards of acceptable medical practice in the United States;
(C) Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms;
(D) Not provided solely for the convenience of the eligible enrollee or the convenience of the health care provider or hospital; and
(E) Not primarily custodial care, unless custodial care is a covered service or benefit under the eligible enrollee's evidence of coverage.
(8) "Treatment" means a medical service, diagnosis, procedure, therapy, drug, or device.
(9) Any term defined in Code Section 33-20A-3 shall have the meaning provided for that term in Code Section 33-20A-3 except that "enrollee" shall include the enrollee's eligible dependents.
Section: 33-20a-30 33-20a-31 33-20a-32 33-20a-33 33-20a-34 33-20a-35 33-20a-36 33-20a-37 33-20a-38 33-20a-39 33-20a-40 33-20a-41 33-20a-42 NextLast modified: October 14, 2016