R590-261-3. Definitions

Terms used in this rule are defined in Section 31A-1-301 and 45 CFR 147.140. Additional terms are defined as follows: (1)(a) "Adverse benefit determination" means: (i) based on the carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, the: (A) denial of a benefit; (B) reduction of a benefit; (C) termination of a benefit; or (D) failure to provide or make payment, in whole or part, for a benefit; or (ii) rescission of coverage. (b) "Adverse benefit determination" includes: (i) denial, reduction, termination, or failure to provide or make payment that is based on a determination of an insured's eligibility to participate in a health benefit plan; (ii) failure to provide or make payment, in whole or part, for a benefit resulting from the application of a utilization review; and (iii) failure to cover an item or service for which benefits are otherwise provided because it is determined to be: (A) experimental; (B) investigational; or (C) not medically necessary or appropriate. (2) "Authorized representative" means: (a) a person to whom an insured has given express written consent for representation in an external review; (b) a person authorized by law to provide substituted consent for an insured; or (c) when the insured is unable to provide consent: (i) a family member of the insured; or (ii) the insured's treating health care provider. (3) "Carrier" means a person that provides health insurance in this state including: (a) an insurance company; (b) a prepaid hospital or medical care plan; (c) a health maintenance organization; (d) a multiple employer welfare arrangement; and (e) any other person providing a health insurance plan under Title 31A, Insurance Code. (4) "Claimant" means the insured or the insured's authorized representative. (5) "Clinical reviewer" means a physician or other appropriate health care provider who: (a) is an expert in the treatment of the medical condition that is the subject of the review; (b) is knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition; (c) holds an appropriate license or certification; and (d) has no history of disciplinary actions or sanctions. (6) "Final adverse benefit determination" means an adverse benefit determination that has been upheld by a carrier at the completion of the carrier's internal review process. (7) "Independent review" means a process that: (a) is a voluntary option for the resolution of a final adverse benefit determination; (b) is conducted at the discretion of the claimant; (c) is conducted by an independent review organization designated by the commissioner; (d) renders an independent and impartial decision on a final adverse benefit determination; and (e) may not require the claimant to pay a fee for requesting the independent review. (8) "Non-formulary drug" means a prescription drug that is not included on a carrier's covered formulary drug list. (9) "Non-formulary drug exception process" means a process for a claimant to request a review of a decision for a drug not covered by the health benefit plan. (10)(a) "Rescission" means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. (b) "Rescission" does not include a cancellation or discontinuance of coverage under a health benefit plan if the cancellation or discontinuance of coverage: (i) has only a prospective effect; or (ii) is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions toward the cost of coverage.