Section Ins 3901.02 - Definitions(a) "Adverse benefit determination" means 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 claimant's eligibility to participate in a plan, and including 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.(b) "Health care professional" means a physician or other health care provider who is licensed, accredited, or certified to perform specified health services consistent with state law.(c) "Relevant to a claimant's claim" means, when used in reference to a document, record or other information, that the document, record or other information: (1) Was relied upon in making the benefit determination;(2) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;(3) Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; or(4) Constitutes a statement of policy or guidance with respect to the carrier's policy concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.N.H. Admin. Code § Ins 3901.02
#8020, eff 3-1-04; ss by #10122, eff 5-1-12