Section Ins 2703.02 - Definitions For the purpose of this rule:
(a) "Adverse determination" means a determination by a health carrier or its designee utilization review entity: (1) Concerning a requested admission, availability of care, continued stay or other health care service, supply or drug that is a covered benefit under the terms of the covered person's health benefit plan or that could be a covered benefit under some circumstances;(2) In which the health carrier or its designee utilization review entity finds that, based upon the information provided, the requested service, supply or drug does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness; and(3) In which the requested service, supply or drug, or payment for such, is therefore denied, reduced, or terminated.(b) "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.(c) "Authorized representative" means a person to whom a covered person has given consent to represent the covered person in an external review. Authorized representative can include the covered person's treating health care professional.(d) "Benefits denial" means a denial, reduction, or termination by a health carrier of a requested health care service, supply or drug, or a denial of payment for such, which is made on the basis of a finding by the health carrier that the requested service, supply or drug is specifically excluded from coverage under the terms of the covered person's health benefit plan and is therefore not a covered benefit.(e) "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.(f) "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.(g) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.(h) "Commissioner" means the insurance commissioner.(i) "Concurrent review" means utilization review conducted during a patient's hospital stay or course of treatment.(j) "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.(k) "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.(l) "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.(m) "Disclose" means to release, transfer or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information.(n) "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.(o) "Final adverse determination" means an adverse determination that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's standard, second level grievance review process as set forth in RSA 420-J:5, V or expedited, second level grievance review process as set forth in RSA 420-J:5, VI (e).(p) "Health benefit plan" means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.(q) "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law.(r) "Health care provider" or "provider" means a health care professional or a facility.(s) "Health care services" or "health services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.(t) "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.(u) "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to: (1) The past, present or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;(2) The provision of health care services to an individual; or(3) Payment for the provision of health care services to an individual.(v) "Independent review organization" means an entity that employs or contracts with clinical peers to conduct independent external reviews of health carrier determinations.(w) "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.(x) "Prospective review" means utilization review conducted prior to an admission or a course of treatment.(y) "Protected health information" means health information: (1) That identifies an individual who is the subject of the information; or(2) With respect to which there is a reasonable basis to believe that the information could be used to identify an individual.(z) "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.(aa) "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.(ab) "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, or settings. Techniques can include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.(ac) "Utilization review organization" means an entity that conducts utilization review, other than a health carrier performing a review for its own health plans.N.H. Admin. Code § Ins 2703.02
#7539, eff 8-1-01; ss by #8862, eff 5-1-07 (from Ins 2703.01 )
Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10918, Effective 9/1/2015, Expires9/1/2025.