33-46-4. Definitions.

As used in this chapter, the term:

“Adverse determination” means a determination based on medical necessity made by a private review agent or utilization review entity not to grant authorization to a hospital, surgical, or other facility or to a healthcare provider’s office for admission, extension of an inpatient stay, or a healthcare service or procedure.#

“Authorization” means a determination by a private review agent or utilization review entity that a healthcare service has been reviewed and, based on the information provided, satisfies the utilization review entity’s requirements for medical necessity.#

“Care management organization” means an entity that is organized for the purpose of providing or arranging healthcare, which has been granted a certificate of authority by the Commissioner of Insurance as a health maintenance organization pursuant to Chapter 21 of this title and which has entered into a contract with the Department of Community Health to provide or arrange for healthcare services on a prepaid, capitated basis to members.#

“Certificate” means a certificate of registration granted by the Commissioner to a private review agent.#

“Claim administrator”’ means any entity that reviews and determines whether to pay claims to covered persons on behalf of the healthcare plan. Such payment determinations are made on the basis of contract provisions including medical necessity and other factors. Claim administrators may be insurers or their designated review organization, self-insured employers, management firms, third-party administrators, or other private contractors.#

“Clinical criteria” means the written policies, decisions, rules, medical protocols, or guidelines used by a private review agent or utilization review entity to determine medical necessity.#

“Clinical peer” means a healthcare provider who is licensed without restriction or otherwise legally authorized and currently in active practice in the same or similar specialty as that of the treating provider, and who typically manages the medical condition or disease at issue and has knowledge of and experience providing the healthcare service or treatment under review.#

“Covered person” means an individual, including, but not limited to, any subscriber, enrollee, member, beneficiary, participant, or his or her dependent, eligible to receive healthcare benefits by a health insurer pursuant to a healthcare plan or other health insurance coverage.#

“Emergency healthcare services” means healthcare services rendered after the recent onset of a medical or traumatic condition, sickness, or injury exhibiting acute symptoms of sufficient severity, including, but not limited to, severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in:#

1. (A)

   Placing the patient’s health in serious jeopardy;#

2. (B)

   Serious impairment to bodily functions; or#

3. (C)

   Serious dysfunction of any bodily organ or part.#

“’Facility” means a hospital, ambulatory surgical center, birthing center, diagnostic and treatment center, hospice, or similar institution. Such term shall not mean a healthcare provider’s office.#

“Health insurer” or “insurer” means an accident and sickness insurer, care management organization, healthcare corporation, health maintenance organization, provider sponsored healthcare corporation, or any similar entity regulated by the Commissioner.#

“Healthcare plan” means any hospital or medical insurance policy or certificate, qualified higher deductible health plan, stand-alone dental plan, health maintenance organization or other managed care subscriber contract, the state health benefit plan, or any plan entered into by a care management organization as permitted by the Department of Community Health for the delivery of healthcare services.#

“Healthcare provider” means any person, corporation, facility, or institution licensed by this state or any other state to provide or otherwise lawfully providing healthcare services, including but not limited to a doctor of medicine, doctor of osteopathy, hospital or other healthcare facility, dentist, nurse, optometrist, podiatrist, physical therapist, psychologist, occupational therapist, professional counselor, pharmacist, chiropractor, marriage and family therapist, or social worker.#

“Healthcare service” means healthcare procedures, treatments, or services provided by a facility licensed in this state or provided within the scope of practice of a doctor of medicine, a doctor of osteopathy, or another healthcare provider licensed in this state. Such term includes but is not limited to the provision of pharmaceutical products or services or durable medical equipment.#

“Medical necessity” or “medically necessary” means healthcare services that a prudent physician or other healthcare provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or its symptoms in a manner that is:#

1. (A)

   In accordance with generally accepted standards of medical or other healthcare practice;#

2. (B)

   Clinically appropriate in terms of type, frequency, extent, site, and duration;#

3. (C)

   Not primarily for the economic benefit of the health insurer or for the convenience of the patient, treating physician, or other healthcare provider; and#

4. (D)

   Not primarily custodial care, unless custodial care is a covered service or benefit under the covered person’s healthcare plan.#

“Member” means a Medicaid or PeachCare for Kids recipient who is currently enrolled in a care management organization plan.#

“Pharmacy benefits manager” means a person, business entity, or other entity that performs pharmacy benefits management. Such term includes a person or entity acting for a pharmacy benefits manager in a contractual or employment relationship in the performance of pharmacy benefits management for a healthcare plan. Such term shall not include services provided by pharmacies operating under a hospital pharmacy license. Such term shall not include health systems while providing pharmacy services for their patients, employees, or beneficiaries, for indigent care, or for the provision of drugs for outpatient procedures. Such term shall not include services provided by pharmacies affiliated with a facility licensed under Code Section 31-44-4 or a licensed group model health maintenance organization with an exclusive medical group contract and which operates its own pharmacies which are licensed under Code Section 26-4-110.#

“Prior authorization” means any written or oral determination made at any time by a claim administrator or an insurer, or any agent thereof, that a covered person’s receipt of healthcare services is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such services have been satisfied. The term “agent” as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.#

“Private review agent” means any person or entity which performs utilization review for:#

1. (A)

   An employer with employees who are treated by a healthcare provider in this state;#

2. (B)

   An insurer; or#

3. (C)

   A claim administrator.#

“State health benefit plan” means the health insurance plan or plans established pursuant to Part 6 of Article 17 of Chapter 2 of Title 20 and Article 1 of Chapter 18 of Title 45 for state and public employees, dependents, and retirees.#

“Urgent healthcare service” means a healthcare service with respect to which the application of the time periods for making a nonexpedited prior authorization, which, in the opinion of a physician or other healthcare provider with knowledge of the covered person’s medical condition:#

1. (A)

   Could seriously jeopardize the life or health of the covered person or the ability of such person to regain maximum function; or#

2. (B)

   Could subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review.#

3. Such term shall include services provided for the treatment of substance use disorders which otherwise qualify as an urgent healthcare service.

“Utilization review” means a system for reviewing the appropriate and efficient allocation or charges of hospital, outpatient, medical, or other healthcare services given or proposed to be given to a patient or group of patients for the purpose of advising the claim administrator who determines whether such services or the charges therefor should be covered, provided, or reimbursed by an insurer according to the benefits plan. Prior authorization is a type of utilization review. Utilization review shall not include the review or adjustment of claims or the payment of benefits arising under liability, workers’ compensation, or malpractice insurance policies as defined in Code Section 33-7-3.#

“Utilization review entity” means an insurer or other entity that performs prior authorization for one or more of the following entities:#

1. (A)

   An insurer that writes health insurance policies;#

2. (B)

   A preferred provider organization or health maintenance organization; or#

3. (C)

   Any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, behavioral health, prescription drug, or other health benefits to a person treated by a healthcare provider in this state under a health insurance policy, plan, or contract.#

“Utilization review plan” means a reasonable description of the standards, criteria, policies, procedures, reasonable target review periods, and reconsideration and appeal mechanisms governing utilization review activities performed by a private review agent or utilization review entity.#