RS 22:1122 Definitions
§1122. Definitions
As used in this Subpart, the following terms shall be defined as follows:
(1) "Adverse determination" means a determination that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and denied, reduced, or terminated by a reviewer based on medical necessity, appropriateness, health care setting, level of care, or effectiveness, or because an item or health care service for which benefits are otherwise provided is determined to be experimental or investigational.
(2) "Ambulatory review" means review of health care services performed or provided in an outpatient setting.
(3) "Appropriate medical information" means all outpatient and inpatient medical records that are pertinent to the evaluation and management of the covered person and that permit the Medical Necessity Review Organization to determine compliance with the applicable clinical review criteria. In the review of coverage for particular services, these records may include but are not necessarily limited to one or more of the following portions of the covered person's medical records as they relate directly to the services under review for medical necessity: admission history and physical examination report, physician's orders, progress notes, nursing notes, operative reports, anesthesia records, hospital discharge summary, laboratory and pathology reports, radiology or other imaging reports, consultation reports, emergency room records, and medication records.
(4) "Authorized representative" means a person to whom a covered person has given written consent to represent the covered person in an internal or external review of an adverse determination of medical necessity. "Authorized representative" may include the covered person's treating provider if the covered person appoints the provider as his authorized representative and the provider waives in writing any right to payment from the covered person other than any applicable copayment or coinsurance amount. In the event that the service is determined not to be medically necessary, and the covered person or his authorized representatives thereafter requests the services, nothing shall prohibit the provider from charging usual and customary charges for all nonmedically necessary services provided.
(5) "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.
(6) "Certification" or "certify" means a determination by a reviewer regarding coverage of an admission, continued stay, or other health care service which, based on the information provided, satisfies the clinical review criteria requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.
(7) "Clinical peer" means a physician or other health care professional who holds a nonrestricted license in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review.
(8) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a reviewer to determine the necessity and appropriateness of covered health care services, including those used in the determination of an item or health care service as experimental or investigational.
(9) "Commissioner" means the commissioner of insurance.
(10) "Concurrent review" means a review of medical necessity, appropriateness of care, or level of care conducted during a patient's stay or course of treatment.
(11) "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.
(12) "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
(13) "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.
(14) "Disclose" means to release, transfer, or otherwise divulge protected health information to any individual, entity, or person other than the individual who is the subject of the protected health information.
(15) "Emergency medical condition" means a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson, acting reasonably and possessing an average knowledge of health and medicine, to believe that the absence of immediate medical attention could reasonably be expected to result in any of the following:
(a) Placing the health of the individual in serious jeopardy.
(b) With respect to a pregnant woman, placing the health of the woman or her unborn child in serious jeopardy.
(c) Serious impairment to bodily function.
(d) Serious dysfunction of any bodily organ or part.
(16) "Entity" means an individual, person, corporation, partnership, association, joint venture, joint stock company, trust, unincorporated organization, any similar entity, agent, or contractor, or any combination of the foregoing.
(17) "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 individual patients.
(18) "External review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations and whose accreditation or certification has been reviewed and approved by the Department of Insurance.
(19) "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 facilities, inpatient hospice facilities, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings.
(20) "Final adverse determination" means an adverse determination that has been upheld by a reviewer at the completion of the medical necessity review organization's internal review process as set forth in this Subpart.
(21) "Health benefit plan" means group and individual health insurance coverage, coverage provided under a group health plan, or coverage provided by a nonfederal governmental plan, as those terms are defined in R.S. 22:1061. "Health benefit plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061(3).
(22) "Health care professional" means a physician or other health care practitioner licensed, certified, or registered to perform specified health services consistent with state law.
(23) "Health care provider" or "provider" means a health care professional or a facility.
(24) "Health care services" means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.
(25) "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 relate to any of the following:
(a) The past, present, or future physical, mental, or behavioral health or condition of a covered person or a member of the covered person's family.
(b) The provision of health care services to a covered person.
(c) Payment for the provision of health care services to a covered person.
(26) "Health insurance coverage" means benefits consisting of medical care provided or arranged for directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract offered by a health insurance issuer.
(27) "Health insurance issuer" means an insurance company, including a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, unless preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974.
(28) "Medical Necessity Review Organization" or "MNRO" means a health insurance issuer or other entity licensed or authorized pursuant to this Subpart to make medical necessity determinations for purposes other than the diagnosis and treatment of a medical condition.
(29) "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 Library of Medicine for indexing in Index Medicus (Medline) or the Manual, Alternative, and Natural Therapy Index System and Elsevier Science Ltd. for indexing in Excerpta Medica (EMBASE).
(c) Medical journals recognized by the secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act as well as the American Journal of Psychiatry, Treatment of Psychiatric Disorders and the American Society for Addiction Medicine.
(d) The following standard reference compendia:
(i) The American Hospital Formulary Service-Drug Information.
(ii) Drug Facts and Comparisons.
(iii) The American Dental Association Accepted Dental Therapeutics.
(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 the following:
(i) The federal Agency for Healthcare Research and Quality.
(ii) The National Institutes of Health.
(iii) The National Cancer Institute.
(iv) The National Academy of Sciences.
(v) The Centers for Medicare & Medicaid Services.
(vi) The federal Food and Drug Administration.
(vii) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services.
(viii) Any other medical or scientific evidence that is comparable to the sources listed in Items (i) through (vii) of this Subparagraph.
(30) "Prospective review" means a review conducted prior to an admission or a course of treatment.
(31) "Protected health information" means health information that either identifies a covered person who is the subject of the information or with respect to which there is a reasonable basis to believe that the information could be used to identify a covered person.
(32) "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but shall 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.
(33) "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 service to assess the clinical necessity and appropriateness of the initial proposed health service.
(34) "Working day" means Monday through Friday, excluding holidays and days upon which an emergency has been declared by state or local government authorities, on which days an MNRO is not able to conduct business in a normal manner.
Acts 1999, No. 401, §1, eff. Jan. 1, 2000; Acts 2003, No. 1109, §1; Redesignated from R.S. 22:3071 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 442, §1, eff. Jan. 1, 2009.
NOTE: See Acts 1999, No. 401, §2, regarding applicability.