W. Va. Code R. § 114-58-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-58-2 - Definitions

2.1. "Adverse determination" means a determination by a managed care plan or its designated utilization review organization that an admission, availability of coverage, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the managed care plan's requirements for medical necessity, or is experimental.

2.2. "Authorized representative" means:

a. A person to whom the enrollee has given express, written consent to represent the enrollee in an external review;

b. A person authorized by law to provide substituted consent for an enrollee, including, but not limited to, a guardian or agent under a power of attorney; or

c. A family member of the enrollee or the enrollee's treating health care professional with the express written permission of the person, or, if incapacitated, a family member, if a situation exists which would warrant an expedited review pursuant to subsection 6.1 of this rule.

2.3. "Commissioner" means the Commissioner of Insurance of the State of West Virginia.

2.4. "Covered benefit" means a health care service for which an enrollee is entitled to payment under the terms of a health care plan.

2.5. "Enrollee" is a natural person on whose behalf a contractual arrangement has been entered into or who has entered into an agreement with a health maintenance organization or prepaid limited health service organization for the provision of managed health care coverage.

2.6. "Experimental" means medical technology or a new application of existing medical technology, including medical procedures, drugs or devices for treating a medical condition, illness or diagnosis that is:

a. Not proven by medical or scientific testing or evidence to be effective in treating the medical condition, illness or diagnosis for which its use is proposed;

b. Not generally recognized by informed health care professionals as effective or appropriate in treating the medical condition, illness or diagnosis for which its use is proposed;

c. Not of proven safety by medical or scientific testing or evidence in treating the medical condition, illness or diagnosis for which its use is proposed;

d. Provided or performed in special settings for research purposes or under a controlled environment or clinical protocol; or

e. Determined to be experimental under the terms of the health benefit plan.

2.7. "External review" means a process, independent of all affected parties, to determine if a health care service is medically necessary or experimental.

2.8. "Health care plan" means a plan that establishes, operates, or maintains a network of health care providers that have entered into agreements with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution. For purposes of this rule, "health care plan" shall not include indemnity health insurance policies including those using a contracted provider network.

2.9. "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

2.10. "Health care provider" or "provider" means a health care professional or an institution which is licensed or otherwise authorized in this state to provide health care services or supplies.

2.11. "Health care services" means services for the diagnosis, prevention, maintenance, treatment, cure or relief of a health condition, illness, injury or disease.

2.12. "Health information" means information or data in any form that relates to:

a. The past, present or future physical, mental or behavioral health or condition of an individual;

b. The provision of health care services to an individual; or

c. Payment for the provision of health care services to an individual.

2.13. "Managed care plan" or "plan" means any health maintenance organization or prepaid limited health service organization; provided, that this rule only applies to prepaid limited health service organizations to the extent of coverage and services these organizations offer.

2.14. "Medical necessity" or "medically necessary" means the determination that a health care service recommended by a health care provider is:

a. The most appropriate available supply or level of service for the enrollee, considering potential benefits and harms to the individual; and

b. Known to be effective in improving health outcomes based on professional standards accepted in and commonly available in the United States for treatment of sickness and injury as determined by the health care plan in accordance with its medical appropriateness criteria. The fact that a health care provider may prescribe, recommend or approve a procedure does not, in itself, make that procedure medically necessary.

2.15. "Protected health information" means information:

a. That identifies an enrollee who is the subject of the information; or

b. With respect to which there is a reasonable basis to believe that the information could be used to identify an enrollee.

2.16. "Religious nonmedical provider" means an individual or institution that provides no medical care but provides only religious nonmedical treatment or religious nonmedical nursing care.

2.17. "Retrospective review" means a review of medical necessity conducted after services have been provided to an enrollee, 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.

2.18. "Utilization review" means a formal system for the evaluation of the necessity, appropriateness, efficiency and cost effectiveness of the use of health care services, procedures and facilities, as defined in section 2 of series 51, Title 114 of the West Virginia Code of State Rules. For purposes of this rule, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a health care service is considered experimental in a given circumstance.

W. Va. Code R. § 114-58-2