§ 420-e-1

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. [Paragraph I-b effective January 1, 2025.] I-b. 'Clinical review criteria' means the written policies, screening procedures, decision abstracts, clinical or medical protocols, practice guidelines, and any other written decision-making standards used by a utilization review entity to determine the medical necessity and appropriateness of health care services. 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

partment' 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. [Paragraph III-a deleted by 2024, 172:9 effective January 1, 2025.] 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. [Paragraph IV effective until January 1, 2025; see also paragraph IV set out below.] 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

d 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. [Paragraph IV effective January 1, 2025; see also paragraph IV set out above.] IV. '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;

ng, 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. [Paragraph V effective January 1, 2025.] V. 'Pre-service claim' means a request for prior authorization. [Paragraph VI effective January 1, 2025.] VI. 'Prior authorization' means the approval from a health carrier or utilization review entity that may be required before a particular health care service, item, or prescription drug is received by the covered person in order for that service, item, or prescription drug to be covered under the covered person's plan. [Paragraph VII effective January 1, 2025.] VII. 'Prior authorization determination' means a determination by a health carrier or utilization review entity that a health care service, item

son's plan. [Paragraph VII effective January 1, 2025.] VII. 'Prior authorization determination' means a determination by a health carrier or utilization review entity that a health care service, item or prescription drug has been reviewed pursuant to a pre-service request for prior authorization and, based on the information provided, satisfies or does not satisfy the health carrier's or utilization review entity's requirements for coverage. [Paragraph VIII effective January 1, 2025.] VIII. '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, 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. Techniques and methods may include, but are not limited to, ambulatory care review, case management, concurrent hospital review, discharge planning, pre-hospital admission certification, pre-inpatient service eligibility certification, prospective review,

to, ambulatory care review, case management, concurrent hospital review, discharge planning, pre-hospital admission certification, pre-inpatient service eligibility certification, prospective review, prior authorization, second opinion, or retrospective review. Source. 1992, 142:2. 1996, 188:12. 2001, 207:4, 5, eff. Jan. 1, 2002. 2024, 172:8, 9, eff. Jan. 1, 2025.