(1) “Adverse determination” means:

(A) A determination by a health carrier or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health carrier's health benefit plan does not meet the health carrier's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness and the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit;

(B) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit based on a determination by a health carrier of a covered person's eligibility to participate in the health carrier's health benefit plan; or

(C) Any prospective review or retrospective review determination that denies, reduces, or terminates or fails to provide or make payment for, in whole or in part, a benefit;

(2) “Aggrieved person” means:

(A) A healthcare provider;

(B) A covered person; or

(C) A covered person's authorized representative;

(3) “Authorized representative” means:

(A) A person to whom a covered person has given express written consent to represent the covered person for purposes of this chapter;

(B) A person authorized by law to provide substituted consent for a covered person;

(C) A family member of the covered person or the covered person's treating healthcare professional when the covered person is unable to provide consent;

(D) A healthcare professional when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the healthcare professional; or

(E) In the case of an urgent care request, a healthcare professional with knowledge of the covered person's medical condition;

(4) “Clinical peer” means a physician or other healthcare professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty that would typically manage the medical condition, procedure or treatment under review;

(5) “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of healthcare services;

(6) “Closed plan” means a managed care plan that requires covered persons to use participating providers under the terms of the managed care plan or the plan will not provide covered benefits to the covered person;

(7) “Commissioner” means the commissioner of commerce and insurance;

(8) “Covered benefits” or “benefits” means those healthcare services to which a covered person is entitled under the terms of a health benefit plan;

(9) “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan;

(10) “Emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy;

(11) “Emergency services” means healthcare items and services furnished or required to evaluate and treat an emergency medical condition;

(12) “External review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations of a health carrier;

(13) “Facility” means an institution licensed under title 68 providing healthcare services or a healthcare setting, including but not 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;

(14) “Final adverse determination” means an adverse determination involving a covered benefit that has been upheld by a health carrier at the completion of the health carrier's internal grievance process procedures as set forth in this chapter;

(15) “Grievance” means a written appeal of an adverse determination or final adverse determination submitted by or on behalf of a covered person regarding:

(A) Availability, delivery or quality of healthcare services regarding an adverse determination;

(B) Claims payment, handling or reimbursement for healthcare services;

(C) Matters pertaining to the contractual relationship between a covered person and a health carrier; or

(D) Matters pertaining to the contractual relationship between a healthcare provider and a health carrier;

(16) “Health benefit plan” means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services;

(17) “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract 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 nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or healthcare services;

(18) “Healthcare professional” means a physician or other healthcare practitioner licensed, accredited or certified to perform specified healthcare services consistent with state law;

(19) “Healthcare provider” or “provider” means a healthcare professional or a facility;

(20) “Healthcare services” means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease;

(21) “Managed care plan” means a health benefit plan that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use healthcare providers managed, owned, under contract with or employed by the health carrier. “Managed care plan” includes:

(A) A closed plan, as defined in subdivision (6); and

(B) An open plan, as defined in subdivision (26);

(22) “Medical or scientific evidence” means evidence found in the following sources; provided, that subdivisions (22)(A)-(B) shall be considered to have more evidentiary value than subdivision (22)(E) and subdivision (22)(E), when considered solely and in the absence of subdivisions (22)(A)-(B), shall not be sufficient to establish medical or scientific evidence for purposes of this chapter:

(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;

(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);

(C) Medical journals recognized by the secretary of health and human services under § 1861(t)(2) of the federal Social Security Act;

(D) The following standard reference compendia:

(i) The American Hospital Formulary Service - Drug Information;

(ii) Drug Facts and Comparisons;

(iii) The American Dental Association Accepted Dental Therapeutics;

(iv) The United States Pharmacopoeia - Drug Information; or

(E) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:

(i) The federal agency for healthcare research and quality;

(ii) The national institutes of health;

(iii) The national cancer institute;

(iv) The national academy of sciences;

(v) The centers for medicare and medicaid services;

(vi) The federal food and drug administration; and

(vii) Any national board recognized by the national institutes of health for the purpose of evaluating the medical value of healthcare services;

(23) “Medically necessary” or “medical necessity” means healthcare services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

(A) In accordance with generally accepted standards of medical practice;

(B) Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient's illness, injury or disease;

(C) Not primarily for the convenience of the patient, physician, or other healthcare provider; and

(D) Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease;

(24) “NAIC” means the National Association of Insurance Commissioners;

(25) “Network” means the group of participating providers providing services to a managed care plan;

(26) “Open plan” means a managed care plan, other than a closed plan, that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan;

(27) “Participating provider” means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide healthcare services to covered persons with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the health carrier;

(28) “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 entities listed in this subdivision (28);

(29) “Prospective review” means utilization review conducted prior to an admission or the provision of a healthcare service or a course of treatment in accordance with a health carrier's requirement that the healthcare service or course of treatment, in whole or in part, be approved prior to its provision or admission;

(30) “Register” means the written records kept by a health carrier to document all grievances received during a calendar year;

(31) “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; and

(32)

(A) “Urgent care request” means a request for a healthcare service or course of treatment with respect to which the time periods for making nonurgent care request determination:

(i) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or

(ii) In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the healthcare service or treatment that is the subject of the request;

(B)

(i) In determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

(ii) Any request that a physician with knowledge of the covered person's medical condition determines is an urgent care request within the meaning of subdivision (32)(A) shall be treated as an urgent care request.