56-6-703 - Part definitions.
56-6-703. Part definitions.
As used in this part, unless the context otherwise requires:
(1) Commissioner means the commissioner of commerce and insurance;
(2) Enrollee means an individual who has contracted for or who participates in coverage under an insurance policy, a health maintenance organization contract, a health service corporation contract, an employee welfare benefit plan, a hospital or medical services plan, or any other benefit program providing payment, reimbursement, or indemnification for health care costs for the individual or the individual's eligible dependents;
(3) Provider of record means the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for the care, treatment, and services rendered to an individual;
(4) (A) Utilization review means a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within this state;
(B) Utilization review does not include elective requests for clarification of coverage; and
(5) Utilization review agent means any person or entity, including the state, performing utilization review, except:
(A) An agency of the federal government;
(B) An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government;
(C) A hospital's internal quality assurance program;
(D) An employee of a utilization review agent; or
(E) Health maintenance organizations licensed and regulated by the commissioner, but only to the extent of providing utilization review to their own members.
[Acts 1992, ch. 812, § 4.]