Definitions

As used in 958 CMR 3.000 the following words shall have the following meanings: Actively Practicing means that a health care professional regularly treats patients in a clinical setting. Adverse Determination means a determination, based upon a review of information provided, by a carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness, including a determination that a requested or recommended health care service or treatment is experimental or investigational. Authorized Representative means an insured's guardian, conservator, holder of a power of attorney, health care agent designated pursuant to M.G.L. c. 210, family member, or other person authorized by the insured in writing or by law with respect to a specific grievance or external review, provided that if the insured is unable to designate a representative, where such designation would otherwise be required, a guardian, conservator, holder of a power of attorney, or family member in that order of priority may be the insured's representative or may appoint another responsible party to serve as the insured's authorized representative. If the authorized representative is a health care provider, the insured must specify a named individual who will act on behalf of the authorized representative and a telephone number for that individual. Carrier means an insurer licensed, or otherwise authorized to transact accident or health insurance under M.G.L. c.175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; a health maintenance organization organized under M.G.L. c. 176G; and an organization entering into a preferred provider arrangement under M.G.L. c. 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer. Carrier shall not include any entity to the extent it offers a policy, certificate or contract that provides coverage solely for dental care services or vision care services. Clinical Review Criteria means the written screening procedures, decisions, abstracts, clinical protocols and practice guidelines used by a carrier to determine the medical necessity and appropriateness of health care services. Commission means the Health Policy Commission. Complaint means: (a) any inquiry made by or on behalf of an insured to a carrier or utilization review organization that is not explained or resolved to the insured's satisfaction within three business days of the inquiry; or (b) any matter concerning an adverse determination. In the case of a carrier or utilization review organization that does not have an internal inquiry process, a complaint means any inquiry. Covered Benefits or Benefits means health care services to which an insured is entitled under the terms of the health benefit plan. Days means calendar days, unless otherwise specified. Evidence of Coverage means any certificate, contract or agreement of health insurance including riders, amendments, endorsements and any other supplementary inserts or a summary plan description pursuant to §104(b)(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1024(b), issued to an insured specifying the benefits to which the insured is entitled. External Review Agency means an independent review organization, which is an entity or company under contract with the Commission to conduct independent reviews of adverse determinations pursuant to M.G.L. c. 176O. Each external review agency shall be accredited by a national accrediting organization. Facility means a licensed institution providing health care services or a health care 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 and other therapeutic health settings. Final Adverse Determination means an adverse determination made after an insured has exhausted all remedies available through a carrier's formal internal grievance process. Financial Affiliation or Financial Relationship means any financial interest in a carrier provided that the term financial affiliation shall not include revenue received from a carrier by a clinical reviewer for health services rendered to insureds. Grievance means any oral or written complaint submitted to the carrier that has been initiated by an insured, or the insured's authorized representative, concerning any aspect or action of the carrier relative to the insured, including, but not limited to, review of adverse determinations regarding scope of coverage, denial of services, rescission of coverage, quality of care and administrative operations, in accordance with the requirements of 958 CMR 3.000. Health Benefit Plan means a policy, contract, certificate or agreement entered into, offered or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. Health Care Professional means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with law. Health Care Provider or Provider means a health care professional or facility. Health Care Services means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. Inquiry means any communication by or on behalf of an insured to the carrier or utilization review organization that has not been the subject of an adverse determination and that requests redress of an action, omission or policy of the carrier. Insured means an enrollee, covered person, insured, member, policy holder or subscriber of a carrier, including an individual whose eligibility as an insured of a carrier is in dispute or under review, or any other individual whose care may be subject to review by a utilization review program or entity as described under the provisions of M.G.L. c. 176O, 211 CMR 52.00: Managed Care Consumer Protections and Accreditation of Carriers and 958 CMR 3.000. Material Familial Affiliation means any relationship as a spouse, child, parent, sibling, spouse's parent, spouse's child, child's parent, child's spouse, sibling's spouse, domestic partner, aunt, uncle, foster parent or foster child. Material Professional Affiliation means any any health care professional-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent contractor arrangement that constitutes a financial affiliation. Medical Necessity or Medically Necessary means health care services that are consistent with generally accepted principles of professional medical practice as determined by whether the service: (a) is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence. Office of Patient Protection means the office within the Commission established by M.G.L. c. 6D, § 16. Participating Provider means a provider who, under a contract with the carrier or with its contractor or subcontractor, has agreed to provide health care services to insureds with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the carrier. Primary Care Provider means a health care professional qualified to provide general medical care for common health care problems, who supervises, coordinates, prescribes, or otherwise provides or proposes health care services, initiates referrals for specialist care, and maintains continuity of care within the scope of his or her practice. Same or Similar Specialty means that the health care professional has similar credentials and licensure as those who typically provide the treatment in question and has experience treating the same condition that is the subject of the grievance. Such experience shall extend to the treatment of children in a grievance involving a child where the age of the patient is relevant to the determination of whether a requested service or supply is medically necessary. Service Area means the geographical area as approved by the Commissioner of Insurance within which the carrier has developed a network of providers to afford adequate access to members for covered health services. Terminal Illness means an illness that is likely, within a reasonable degree of medical certainty, to cause one's death within six months, or as otherwise defined in § 1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(A)). Utilization Review means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include, but are not limited to, ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization Review Organization means an entity that conducts utilization review under contract with or on behalf of a carrier, but does not include a carrier performing utilization review for its own health benefit plans.