W. Va. Code R. § 114-97-2

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

Section 114-97-2 - Definitions

2.1. "Adverse determination" means a determination by an issuer or its designee utilization review organization that an admission, availability of care, continued stay or other healthcare service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the issuer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and the requested service or payment for the service is therefore denied, reduced or terminated.

2.2. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.

2.3. "Authorized representative" means:

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

2.3.b. A person authorized by law to provide substituted consent for a covered person;

2.3.c. In a situation in which a covered person is unable to provide consent, a family member of the covered person or the covered person's treating health care professional;

2.3.d. A health care professional when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional; or

2.3.e. In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.

2.4. "Best evidence" means evidence based on:

2.4.a. A controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time ("randomized clinical trial");

2.4.b. If randomized clinical trials are not available, a prospective evaluation of two groups of patients with only one group of patients receiving specific interventions ("cohort studies") or a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received ("case-control studies");

2.4.c. If subdivisions 2.4.a and 2.4.b are not available, an evaluation of a series of patients with a particular outcome, without the use of a control group ("case-series"); or

2.4.d. If subdivisions 2.4.a, 2.4.b and 2.4.c are not available, a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention or therapy ("expert opinion").

2.5. "Certification" means a determination by an issuer or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit under the issuer's health benefit plan has been reviewed and, based on the information provided, satisfies the issuer's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.

2.6. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the issuer to determine the medical necessity and appropriateness of health care services.

2.7. "Commissioner" means the West Virginia Insurance Commissioner.

2.8. "Concurrent review" means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting.

2.9. "Covered benefits" or "benefits" means those health care services to which a covered person is legally entitled under the terms of a health benefit plan.

2.10. "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan; whenever this rule provides for action by or notice to a covered person, it shall be deemed to include action by or notice to such covered person's authorized representative.

2.11. "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.

2.12. "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

2.13. "Emergency services" means with respect to an emergency medical condition:

2.13.a. A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

2.13.b. Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities available at a hospital, to stabilize a patient.

2.14. "Evidence-based standard" means the conscientious, explicit and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients.

2.15. "Facility" means an institution providing health care services or a health care setting, including but no 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.

2.16. "Final adverse determination" means an adverse determination that has been upheld by the issuer at the completion of the internal grievance procedures or an adverse determination with respect to which the internal grievance procedures have been exhausted.

2.17. "Health benefit plan" means a policy, contract, certificate or agreement entered into, offered or issued by an issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including short term and catastrophic health insurance policies and a policy that pays on a cost-incurred basis, but excluding the excepted benefits defined in 42 U.S.C. § 300gg-91 and as otherwise specifically excepted in this rule.

2.17.a. "Health benefit plan" does not include:

2.17.a.1. Coverage only for accident, or disability income insurance or any combination thereof;

2.17.a.2. Coverage issued as a supplement to liability insurance;

2.17.a.3. Liability insurance, including general liability insurance and automobile liability insurance;

2.17.a.4. Workers' compensation or similar insurance;

2.17.a.5. Automobile medical payment insurance;

2.17.a.6. Credit-only insurance;

2.17.a.7. Coverage for on-site medical clinics; and

2.17.a.8. Other similar insurance coverage specified in federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits.

2.17.b. "Health benefit plan" does not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:

2.17.b.1. Limited scope dental or vision benefits;

2.17.b.2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or

2.17.b.3. Other similar, limited benefits specified in federal regulations issued pursuant to Pub. L. No. 104-191.

2.17.c. "Health benefit plan" does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:

2.17.c.1. Coverage only for a specified disease or illness; or

2.17.c.2. Hospital indemnity or other fixed indemnity insurance.

2.17.d. "Health benefit plan" does not include the following if offered as a separate policy, certificate or contract of insurance:

2.17.d.1. Medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act;

2.17.d.2. Coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)); or

2.17.d.3. Similar supplemental coverage provided to coverage under a group health plan.

2.18. "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.

2.19. "Health care provider" or "provider" means a health care professional or a facility.

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

2.21. "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:

2.21.a. The past, present or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;

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

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

2.22. "Independent review organization" or "IRO" means an entity, approved by the Commissioner to conduct external reviews of adverse determinations and final adverse determinations.

2.23. "Issuer" means an entity required to be licensed under the insurance laws and regulations of West Virginia 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 accident and sickness insurance company, a health maintenance organization, a nonprofit hospital or health service corporation, fraternal benefit society, or any other entity providing a health benefit plan.

2.24. "Medical or scientific evidence" means evidence found in the following sources:

2.24.a. Peer reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

2.24.b. Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE);

2.24.c. Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act;

2.24.d. The following standard reference compendia:

2.24.d.1. The American Hospital Formulary Service-Drug Information;

2.24.d.2. Drug Facts and Comparisons;

2.24.d.3. The American Dental Association Accepted Dental Therapeutics; and

2.24.d.4. The United States Pharmacopeia-Drug Information;

2.24.e. Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:

2.24.e.1. The federal Agency for Healthcare Research and Quality;

2.24.e.2. The National Institutes of Health;

2.24.e.3. The National Cancer Institute;

2.24.e.4. The National Academy of Sciences;

2.24.e.5. The Centers for Medicare & Medicaid Services;

2.24.e.6. The federal Food and Drug Administration; and

2.24.e.7. Any national board recognized by the National Institutes of health for the purpose of evaluating the medical value of health care services; or

2.24.f Any other medical or scientific evidence that is comparable to the sources listed in subdivisions a through e of this subsection.

2.25. "NAIC" means the National Association of Insurance Commissioners.

2.26. "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.

2.27. "Prospective review" means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with an issuer's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision.

2.28. "Protected health information" means health information:

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

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

2.29. "Retrospective review" means any review of a request for a benefit that is not a prospective review request. "Retrospective review" does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.

2.30. "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by a provider other than that originally making a recommendation for a proposed health care service to assess the medical necessity and appropriateness of the initial proposed health care service.

2.31. "Utilization review" means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities.

2.32. "Utilization review organization" means an entity that conducts utilization review, other than an issuer performing utilization review for its own health benefit plans.

W. Va. Code R. § 114-97-2