Definitions

Definitions (1) Adverse determination: A determination by a health insurance issuer that, based on the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational 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; the denial, reduction, or termination of or failure to provide or make payment, in whole or in part, for a benefit based on a determination by a health insurance issuer that a preexisting condition was present before the effective date of coverage; or a rescission of coverage determination, which does not include a cancellation or discontinuance of coverage that is attributable to a failure to timely pay required premiums or contributions toward the cost of coverage. (2) Appeal: A formal request, either orally or in writing, to reconsider an adverse determination. (3) Approval: A determination by a health insurance issuer that a health care service has been reviewed and, based on the information provided, satisfies the health insurance issuer's requirements for medical necessity and appropriateness. (4) Attending Physician: The physician with primary responsibility for the care provided to a patient in a hospital or other health care facility. (5) Certificate: A certificate of registration granted by the Mississippi Insurance Department to a private review agent, and is not transferable. Any valid and active certificate issued by the Mississippi Department of Health prior to July 1, 2024, shall be honored by the Mississippi Department of Insurance until such time as the expiration or revocation of said certificate. (6) Certification: A determination by a utilization review organization that an admission, extension of stay, or other medical service has been reviewed and based on the information provided, qualifies as medically necessary and appropriate under the medical review requirements of the applicable health benefit plan. (7) Certification Number: The number assigned to each certified private review agent. This number is not transferable. (8) Certified Private Review Agent: A private review agent who meets all the criteria for certification as set forth in these rules and regulations, has paid all current fees, and has been assigned a certification number. (9) Chronic Condition. A medical condition that is medically complex, life threatening, long-term, or substantially disabling, including, but not limited to, chemotherapy for the treatment of cancer. Treatment for a chronic condition may include a recurring health care service or maintenance medication. (10) Commissioner. The Commissioner of Insurance. (11) Clinical review criteria: The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a health insurance issuer to determine the necessity and appropriateness of health care services. (12) Concurrent Review: Utilization review conducted during a patient's hospital stay or course of treatment. (13) Consulting Physician: A Medical Doctor, Doctor of Osteopathy, Dentist, Psychologist, Podiatrist or Chiropractor who possess the degree of skill ordinarily possessed and used by members of his or her profession in good standing, and actively engaged in the same type of practice and relevant specialty. The medical and osteopathy specialist shall be certified by the Boards within the American Board of Medical Specialists or the American Board of Osteopathy. (14) Department: The Mississippi Insurance Department. (15) Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part. (16) Emergency services: Health care items and services furnished or required to evaluate and treat an emergency medical condition. (17) Enrollee: The individual who has elected to contract for, or participate in, a health benefit plan for their self and/or their dependents. (18) Expedited Appeal: A request for additional review of a utilization review organization's determination not to certify an admission, extension of stay, or other medical service. An expedited appeal request may be called a reconsideration request by some utilization review organizations. (19) Health care professional: A physician, a registered professional nurse or other individual appropriately licensed or registered to provide health care services (20) Health care provider: Any physician, hospital, ambulatory surgery center, or other person or facility that is licensed or otherwise authorized to deliver health care services. (21) Health care service. Any services or level of services included in the furnishing to an individual of medical care or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human illness or injury, including behavioral health, mental health, home health and pharmaceutical services and products. (22) Health insurance issuer: Shall have the meaning given to that term in Miss. Code Ann. §83-9-6.3, and all private review agents and utilization review plans, as both terms are defined in Miss. Code Ann. §41-83-1, with the exception of employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974 or health care provided pursuant to the Workers' Compensation Act. (23) Hospital: An institution which is primarily engaged in providing to inpatients and outpatients, by or under the supervision of physicians, diagnostic services and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation services for the rehabilitation of injured, disabled or sick persons, and also, means a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and illness, disease, injury or deformity, or a place devoted primarily to providing obstetrical or other medical, surgical or nursing care of individuals, whether or not any such place be organized or operated for profit and whether any such place be publicly or privately owned. The term "Hospital" does not include convalescent or boarding homes, children's homes, homes for the aged or other like establishments where room and board only are provided, nor does it include offices or clinics where patients are not regularly kept as bed patients. The term ”Hospital” includes Rural Emergency Hospitals which are licensed as such through the Mississippi Department of Health. (24) Medically Necessary: A health care professional exercising prudent clinical judgment would provide care to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms and that are: a. In accordance with generally accepted standards of medical practice; and b. Clinically appropriate in terms of type, frequency, extent, site and duration and are considered effective for the patient's illness, injury or disease; and not primarily for the convenience of the patient, treating physician, other health care professional, caregiver, family member or other interested party, but focused on what is best for the patient's health outcome. (25) Patient: The intended recipient of the proposed health care, his/her representative, and/or the enrollee. (26) Physician: Any person with a valid doctor of medicine, doctor of osteopathy or doctor of podiatry degree. (27) Physician Advisor: A physician representing the claim administrator/utilization review organization who provides advice on whether to certify an admission, extension of stay, or other medical service as being medically necessary and appropriate. (28) Private Review Agent: A non-hospital affiliated person or entity performing utilization review on behalf of: a. An employer or employees in the State of Mississippi; or b. A third party that provides or administers hospital and medical benefits to citizens of this state, including: a health maintenance organization issued a certificate of authority under and by virtue of the laws of the State of Mississippi, or a health insurer, nonprofit health service plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state. (29) Prior authorization: The process by which a health insurance issuer determines the medical necessity and medical appropriateness of an otherwise covered health care service before the rendering of such health care service. "Prior authorization" includes any health insurance issuer's requirement that an enrollee, health care professional or health care provider notify the health insurance issuer before, at the time of, or concurrent to providing a health care service. (30) Provider Utilization Review Representative: The person(s) in a physician's office or hospital designated by the physician or hospital to provide the necessary information to complete the review process. (31) Review Criteria: The written policies, decision rules, medical protocols, or guides used by the utilization review organization to determine certification [e.g., Appropriateness Evaluation Protocol (AEP) and Intensity of Service, Severity of Illness, Discharge, and Appropriateness Screens (ISD-A)]. (32) Urgent health care service: A health care service with respect to which the application of the time periods for making a non-expedited prior authorization that in the opinion of a treating health care professional or health care provider with knowledge of the enrollee's medical condition: a. Could seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; b. Could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review; or c. Could lead to likely onset of an emergency medical condition if the service is not rendered during the time period to render a prior authorization determination for an urgent medical service. (33) Urgent health care service: For the purposes of this regulation, urgent health care service does not include emergency services. (34) Utilization Review: A system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. More specifically, utilization review refers to pre-service determination of the medical necessity or appropriateness of services to be rendered in a hospital setting either on an inpatient or outpatient basis, when such determination results in approval or denial of payment for the services. It includes both prospective and concurrent review and may include retrospective review under certain circumstances. (35) Utilization Review Plan: A description of the utilization review procedures of a private review agent.