Section 420-E:1 Definitions.
In this chapter:
I. ""Commissioner'' means the insurance commissioner.
I-a. ""Claim involving urgent care'' means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:
(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
II. ""Department'' means the insurance department.
III. ""Health care provider'' means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist or psychologist, and any officer, employee or agent of such provider acting in the course and scope of his employment or agency related to or supportive of health care services.
III-a. ""Pre-service claim'' means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
IV. ""Utilization review'' means a system for reviewing the appropriate and efficient allocation of hospital, medical or other health care services given to a patient or group of patients as to necessity, for the purpose of recommending or determining whether such services should be covered or provided by an insurer, nonprofit service organization, health maintenance organization, third-party administrator or employer. The terms include those programs or processes whether they apply prospectively or retrospectively to medical services. Utilization review services include, but are not limited to, the following: second opinion programs; prehospital admission certification; preinpatient service eligibility certification; and concurrent hospital review to determine appropriate length of stay. Utilization review shall not include claims review or decisions.
Source. 1992, 142:2. 1996, 188:12. 2001, 207:4, 5, eff. Jan. 1, 2002.