Section 230-RICR-20-30-9.3 - DefinitionsA. As used in this regulation: 1. "Active treatment" means; a. An ongoing course of treatment for a life-threatening condition;b. An ongoing course of treatment for an acute medical, behavioral health, dental, vision or other clinical condition;c. The second or third trimester of what has been documented as a non-high-risk pregnancy; and/or d. An ongoing course of treatment for a health condition which a treating provider substantiates that discontinuing care by that provider would worsen the condition or clinical outcome of that beneficiary.2. "Adverse benefit determination" means a decision not to authorize a health care service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization review agent to authorize a health care service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse determination if the review agent and provider are in agreement regarding the decision. Adverse benefit determinations include: a. "Administrative adverse benefit determinations," meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, a determination that an administrative requirement was not followed or any rescission of coverage; and;b. "Non-administrative adverse benefit determinations," meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the health care entity's formulary.3. "Appeal" or "Internal appeal" means a subsequent review of an adverse benefit determination upon request by a claimant to include the beneficiary or provider to reconsider all or part of the original adverse benefit determination.4. "Authorized representative" means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary.5. "Beneficiary" means a policy holder subscriber, enrollee, or other individual participating in a health benefit plan.6. "Benefit determination" means a decision to approve or deny a request to provide or make payment for a health care service or treatment.7. "Certificate" means a certificate granted by the Commissioner to a health care entity meeting the requirements of this chapter.8. "Commissioner" means the Commissioner of the Office of the Health Insurance Commissioner.9. "Complaint" or "Grievance" means an oral or written expression of dissatisfaction by a beneficiary, authorized representative, or provider. The appeal of an adverse benefit determination is not considered a complaint or grievance.10. "Covered service" or "Covered benefit" means those health care services to which a beneficiary is entitled under the terms of the health benefit plan.11. "Delegate" means a person or other party authorized pursuant to a delegation of authority or directly or re-delegation of authority, by a health care entity or network plan to perform one or more of the functions and responsibilities of a health care entity and/or network plan set forth in the Act or regulations or guidance promulgated thereunder.12. "Emergency services" or "Emergent services" means those resources provided in the event of the sudden onset of a medical, behavioral health, or other health condition that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in placing the patient's health in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of any bodily organ or part.13. "Health benefit plan" or "Health plan" means a policy, contract, certificate, or agreement entered into, offered, or issued by a health care entity to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.14. "Health care entity" means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the Commissioner or the jurisdiction of the department of business regulation that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing health insurance, accident and sickness insurance, health benefits, or health care services. Entity shall have the same meaning as health care entity for purposes of these regulations.15. "Health care services" means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary's health benefit plan.16. "Material change" means a substantial systemic change determined by the Office, that could reasonably be expected to adversely affect the access, availability, quality or continuity of services for a significant number of beneficiaries of a health care entity to include, but not limited to the following: a. Termination of a hospital or facility contract;b. Termination of professional provider contract(s);c. Professional provider contract changes affecting any one professional provider specialty within any of the health care entity's network plans;d. A change to the tiered products, multi-tiered, layered or multi-level network plan structures during a network plan contract year;e. Termination or transition of any Benefit Determination delegate;f. Surrender or withdrawal of any network plan holding a certificate under the Act or these regulations; org. Other operational and network plan changes that meet the definition of material change.17. "Most-favored-rate clause" means a provision in a provider contract whereby the rates or fees to be paid by a health care entity are fixed, established, or adjusted to be equal to or lower than the rates or fees paid to the provider by any other health care entity.18. "Network" means the group or groups of participating providers providing health care services under a network plan.19. "Network plan" means a health benefit plan or health plan that either requires a beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the providers managed, owned, under contract with, or employed by the health care entity.20. "Office" means the Office of the Health Insurance Commissioner.21. "Participating provider" or "Network provider" means a provider under contract with a health care entity, or one of its delegates, who has agreed under this contract to provide health care services to the health care entity's beneficiaries with an expectation of receiving payment, other than coinsurance, copayments, or deductibles from the beneficiary, only from the health care entity under the terms of the contract.22. "Professional provider" means an individual provider or health care professional licensed, accredited, or certified to perform specified health care services consistent with state law and who provides these health care services and is not part of a separate facility or institutional contract.23. "Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider, or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.24. "Substantial systemic change" means any modification of a health care entity's network plan's contracting, credentialing, operational policies and/or procedures relevant to these regulations adversely affecting beneficiaries, a group of providers, an entire specialty provider type, a hospital, a facility provider, or a delegate having responsibilities, or any other health care entity's modification relevant to these regulations that may impact a significant portion of its beneficiaries' access to a network provider, the availability of network providers, or the quality and continuity of care.25. "Tiered network" means a network that identifies and groups some or all types of providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, or provider access requirements, or any combination thereof, apply for the same services.230 R.I. Code R. 230-RICR-20-30-9.3
Adopted effective 12/16/2018