Section 22:1060.12 - DefinitionsAs used in this Subpart, the following definitions apply unless the context indicates otherwise:
(1) "Health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident including a group insurance plan or self-insurance plan and the office of group benefits. "Health coverage plan" does not include a plan providing coverage for excepted benefits defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.(2) "Health insurance issuer" means an entity subject to the Louisiana Insurance Code and applicable regulations, or subject to the jurisdiction of the commissioner, 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 healthcare services, including a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits.(3) "Nationally recognized clinical practice guidelines" means evidence-based clinical guidelines developed by independent organizations or medical professional societies, including but not limited to the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Society of Hematology, utilizing a transparent methodology and reporting structure and having policies against conflicts of interest. The guidelines shall establish best practices informed by a systematic review of evidence, an assessment of the benefits and costs of alternative care options, and recommendations intended to optimize patient care.(4) "Positron emission tomography" means an imaging test that uses radioactive substances to visualize and measure metabolic processes in the body to help reveal how tissue and organs are functioning. The provisions of this Section shall not apply to non-melanomatous skin cancer.(5) "Prior authorization" means a determination by a health insurance issuer or person contracting with a health insurance issuer that healthcare services ordered by the provider to an individual or an enrollee are medically necessary and appropriate.(6) "Utilization review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, healthcare services, procedures, or settings. Techniques include but are not limited to ambulatory review, prior authorization, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. "Utilization review" does not include elective requests for clarification of coverage.(7) "Consensus statements" means statements developed by an independent, multidisciplinary panel of experts utilizing a transparent methodology and reporting structure and with a conflict-of-interest policy that are published in impactful scientific journals. The statements are aimed at specific, and often times rare, clinical circumstances and based on the best available evidence for the purpose of optimizing the outcomes of clinical care. Amended by Acts 2024, No. 162,s. 1, eff. 5/23/2024, app. 1/1/2025.Added by Acts 2023, No. 254,s. 1, eff. 8/1/2023, app. 1/1/2024.