420-J:3 Definitions. –
In this chapter:
I. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service is therefore denied, reduced, or terminated.
II. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.
III. "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, attending physician, facility or health care provider can contest an adverse determination rendered by the health carrier or its designee utilization review organization, which results in the denial, reduction or termination of a requested health care service.
III-a. "Authorized representative" means a person to whom a covered person has given consent to represent the covered person in an external review. Authorized representative may include the covered person's treating provider.
IV. "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.
V. "Certification" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.
V-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.
V-b. "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.
V-c. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.
VI. "Clinical peer" means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. A "clinical peer" includes a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the health care professional who made the initial decision.
VII. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services.
VIII. "Commissioner" means the insurance commissioner.
IX. "Concurrent hospital review" means utilization review conducted during a patient's inpatient stay or course of treatment.
X. "Consumer" means someone in the general public who may or may not be a covered person or a purchaser of health care including employers.
X-a. "Contracted pharmacy" or "pharmacy" means a pharmacy participating in the network of a pharmacy benefit manager through a direct contract or through a contract with a pharmacy services administration organization or group purchasing organization.
XI. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.
XII. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
XIII. "Credentialing verification" is the process of obtaining and verifying information about a health care professional, and evaluating that health care professional, when that health care professional applies to become a participating provider in a managed care plan offered by a health carrier.
XIV. "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.
XIV-a. "Drug product reimbursement" means the amount paid by a carrier or pharmacy benefit manager to a contracted pharmacy or pharmacist for the cost of the drug dispensed to a patient and does not include a dispensing or professional fee.
XV. "Emergency medical condition" means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention such that a prudent layperson with average knowledge of health and medicine could reasonably expect that failure to provide medical attention could result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or could place the person's health in serious jeopardy.
XVI. "Emergency services" means health care services that are provided to an enrollee, insured, or subscriber in a licensed hospital emergency facility by a provider after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson with average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could result in any of the following:
(a) Serious jeopardy to the patient's health.
(b) Serious impairment to bodily functions.
(c) Serious dysfunction of any bodily organ or part.
XVII. "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 centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
XVIII. "Grievance" means a written complaint submitted by or on behalf of a covered person regarding the:
(a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b) Claims payment, handling, or reimbursement for health care services; or
(c) Matters pertaining to the contractual relationship between a covered person and a health carrier.
XIX. "Health benefit plan" means a policy, contract certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
XX. "Health care professional" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law.
XXI. "Health care provider" or "provider" means a health care professional or facility.
XXII. "Health care services" or "health services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
XXIII. "Health carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company, a health maintenance organization, a health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services.
XXIII-a. "Independent review organization" means an entity that employs or contracts with clinical peers to conduct independent external reviews of health carrier determinations.
XXIV. "Intermediary" means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network.
XXV. "Managed care plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.
XXV-a. "Medical director" means a physician licensed under RSA 329 and employed by a health carrier or medical utilization review entity who is responsible for the utilization review techniques and methods of the health carrier or medical utilization review entity and their administration and implementation.
XXV-b. "Medical necessity" means health care services or products provided to an enrollee for the purpose of preventing, stabilizing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:
(a) Consistent with generally accepted standards of medical practice;
(b) Clinically appropriate in terms of type, frequency, extent, site, and duration;
(c) Demonstrated through scientific evidence to be effective in improving health outcomes;
(d) Representative of "best practices" in the medical profession; and
(e) Not primarily for the convenience of the enrollee or physician or other health care provider.
XXVI. "Network" means the group of participating providers providing services to a managed care plan.
XXVII. "Participating provider" means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.
XXVIII. "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.
XXVIII-a. "Pharmacy benefits manager" means "pharmacy benefits manager" as defined in RSA 402-N:1, VIII.
XXVIII-b. "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. "Pre-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.
XXVIII-aa. "Post-service claim" means any claim for a health benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care or disability benefit. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.
XXIX. "Prospective review" means utilization review conducted prior to an admission or a course of treatment.
XXX. "Quality assessment" means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations.
XXXI. "Quality improvement" means the effort to improve the processes and outcomes related to the provision of health care services within the health benefit plan.
XXXII. "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include a claims settlement process including an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, adjudication for payment, or whether a service is a covered benefit under the plan.
XXXIII. "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.
XXXIV. "Utilization review" means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services procedures, providers, or facilities. Techniques and methods may include ambulatory care review, case management, concurrent hospital review, discharge planning, prehospital admission certification, preinpatient service eligibility certification, prospective review, second opinion, or retrospective review.
XXXV. "Utilization review entity" means an entity, subject to licensure pursuant to RSA 420-E, that conducts utilization review, other than a health carrier performing review for its own health plans.