§ 23-17.12-2 - Definitions.
SECTION 23-17.12-2
§ 23-17.12-2 Definitions. – As used in this chapter, the following terms are defined as follows:
(1) "Adverse determination" means a utilization reviewdecision by a review agent not to authorize a health care service. A decisionby a review agent to authorize a health care service in an alternative setting,a modified extension of stay, or an alternative treatment shall not constitutean adverse determination if the review agent and provider are in agreementregarding the decision. Adverse determinations include decisions not toauthorize formulary and nonformulary medication.
(2) "Appeal" means a subsequent review of an adversedetermination upon request by a patient or provider to reconsider all or partof the original decision.
(3) "Authorization" means the review agent's utilizationreview, performed according to subsection 23-17.12-2(20), concluded that theallocation of health care services of a provider, given or proposed to be givento a patient was approved or authorized.
(4) "Benefit determination" means a decision of theenrollee's entitlement to payment for covered health care services as definedin an agreement with the payor or its delegate.
(5) "Certificate" means a certificate of registration grantedby the director to a review agent.
(6) "Complaint" means a written expression of dissatisfactionby a patient, or provider. The appeal of an adverse determination is notconsidered a complaint.
(7) "Concurrent assessment" means an assessment of themedical necessity and/or appropriateness of health care services conductedduring a patient's hospital stay or course of treatment. If the medical problemis ongoing, this assessment may include the review of services after they havebeen rendered and billed. This review does not mean the elective requests forclarification of coverage or claims review or a provider's internal qualityassurance program except if it is associated with a health care financingmechanism.
(8) "Department" means the department of health.
(9) "Director" means the director of the department of health.
(10) "Emergent health care services" has the same meaning asthat meaning contained in the rules and regulations promulgated pursuant tochapter 12.3 of title 42 as may be amended from time to time and includes thoseresources provided in the event of the sudden onset of a medical, mentalhealth, or substance abuse or other health care condition manifesting itself byacute symptoms of a severity (e.g. severe pain) where the absence of immediatemedical attention could reasonably be expected to result in placing thepatient's health in serious jeopardy, serious impairment to bodily or mentalfunctions, or serious dysfunction of any body organ or part.
(11) "Patient" means an enrollee or participant in allhospital or medical plans seeking health care services and treatment from aprovider.
(12) "Payor" means a health insurer, self-insured plan,nonprofit health service plan, health insurance service organization, preferredprovider organization, health maintenance organization or other entityauthorized to offer health insurance policies or contracts or pay for thedelivery of health care services or treatment in this state.
(13) "Practitioner" means any person licensed to provide orotherwise lawfully providing health care services, including, but not limitedto, a physician, dentist, nurse, optometrist, podiatrist, physical therapist,clinical social worker, or psychologist.
(14) "Prospective assessment" means an assessment of themedical necessity and/or appropriateness of health care services prior toservices being rendered.
(15) "Provider" means any health care facility, as defined in§ 23-17-2 including any mental health and/or substance abuse treatmentfacility, physician, or other licensed practitioners identified to the reviewagent as having primary responsibility for the care, treatment, and servicesrendered to a patient.
(16) "Retrospective assessment" means an assessment of themedical necessity and/or appropriateness of health care services that have beenrendered. This shall not include reviews conducted when the review agency hasbeen obtaining ongoing information.
(17) "Review agent" means a person or entity or insurerperforming utilization review that is either employed by, affiliated with,under contract with, or acting on behalf of:
(i) A business entity doing business in this state;
(ii) A party that provides or administers health carebenefits to citizens of this state, including a health insurer, self-insuredplan, non-profit health service plan, health insurance service organization,preferred provider organization or health maintenance organization authorizedto offer health insurance policies or contracts or pay for the delivery ofhealth care services or treatment in this state; or
(iii) A provider.
(18) "Same or similar specialty" means a practitioner who hasthe appropriate training and experience that is the same or similar as theattending provider in addition to experience in treating the same problems toinclude any potential complications as those under review.
(19) "Urgent health care services" has the same meaning asthat meaning contained in the rules and regulations promulgated pursuant tochapter 12.3 of title 42 as may be amended from time to time and includes thoseresources necessary to treat a symptomatic medical, mental health, or substanceabuse or other health care condition requiring treatment within a twenty-four(24) hour period of the onset of such a condition in order that the patient'shealth status not decline as a consequence. This does not include thoseconditions considered to be emergent health care services as defined insubdivision (10).
(20) "Utilization review" means the prospective, concurrent,or retrospective assessment of the necessity and/or appropriateness of theallocation of health care services of a provider, given or proposed to be givento a patient. Utilization review does not include:
(i) Elective requests for the clarification of coverage; or
(ii) Benefit determination; or
(iii) Claims review that does not include the assessment ofthe medical necessity and appropriateness; or
(iv) A provider's internal quality assurance program exceptif it is associated with a health care financing mechanism; or
(v) The therapeutic interchange of drugs or devices by apharmacy operating as part of a licensed inpatient health care facility; or
(vi) The assessment by a pharmacist licensed pursuant to theprovisions of chapter 19 of title 5 and practicing in a pharmacy operating aspart of a licensed inpatient health care facility in the interpretation,evaluation and implementation of medical orders, including assessments and/orcomparisons involving formularies and medical orders.
(21) "Utilization review plan" means a description of thestandards governing utilization review activities performed by a private reviewagent.
(22) "Health care services" means and includes an admission,diagnostic procedure, therapeutic procedure, treatment, extension of stay, theordering and/or filling of formulary or nonformulary medications, and any otherservices, activities, or supplies that are covered by the patient's benefitplan.
(23) "Therapeutic interchange" means the interchange orsubstitution of a drug with a dissimilar chemical structure within the sametherapeutic or pharmacological class that can be expected to have similaroutcomes and similar adverse reaction profiles when given in equivalent doses,in accordance with protocols approved by the president of the medical staff ormedical director and the director of pharmacy.