CHAPTER 27-18.9
Benefit Determination and Utilization Review Act [Effective January 1, 2018.]

SECTION 27-18.9-2

§ 27-18.9-2. Definitions. [Effective January 1, 2018.].

As used in this chapter, the following terms are defined as follows:

(1) "Adverse benefit determination" means a decision not to authorize a health care service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a health care service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse determination if the review agent and provider are in agreement regarding the decision. Adverse benefit determinations include:

(i) "Administrative adverse benefit determinations," meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and

(ii) "Non-administrative adverse benefit determinations," meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the health care entity's formulary.

(2) "Appeal" or "internal appeal" means a subsequent review of an adverse benefit determination upon request by a claimant to include the beneficiary or provider to reconsider all or part of the original adverse benefit determination.

(3) "Authorization" means a review by a review agent, performed according to this chapter, concluding that the allocation of health care services ordered by a provider, given or proposed to be given to a beneficiary, was approved or authorized.

(4) "Authorized representative" means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary.

(5) "Beneficiary" means a policy-holder subscriber, enrollee, or other individual participating in a health benefit plan.

(6) "Benefit determination" means a decision to approve or deny a request to provide or make payment for a health care service or treatment.

(7) "Certificate" means a certificate granted by the commissioner to a review agent meeting the requirements of this chapter.

(8) "Claim" means a request for plan benefit(s) made by a claimant in accordance with the health care entity's reasonable procedures for filing benefit claims. This shall include pre-service, concurrent, and post-service claims.

(9) "Claimant" means a health care entity participant, beneficiary, and/or authorized representative who makes a request for plan benefit(s).

(10) "Commissioner" means the health insurance commissioner.

(11) "Complaint" means an oral or written expression of dissatisfaction by a beneficiary, authorized representative, or a provider. The appeal of an adverse benefit determination is not considered a complaint.

(12) "Concurrent assessment" means an assessment of health care services conducted during a beneficiary's hospital stay, course of treatment or services over a period of time, or for the number of treatments. If the medical problem is ongoing, this assessment may include the review of services after they have been rendered and billed.

(13) "Concurrent claim" means a request for a plan benefit(s) by a claimant that is for an ongoing course of treatment or services over a period of time or for the number of treatments.

(14) "Delegate" means a person or entity authorized pursuant to a delegation of authority or re-delegation of authority, by a health care entity or network plan to perform one or more of the functions and responsibilities of a health care entity and/or network plan set forth in this chapter or regulations or guidance promulgated thereunder.

(15) "Emergency services" or "emergent services" means those resources provided in the event of the sudden onset of a medical, behavioral health, or other health condition that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in placing the patient's health in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of any bodily organ or part.

(16) "External review" means a review of a non-administrative adverse benefit determination (including final internal adverse benefit determination) conducted pursuant to an applicable external review process performed by an independent review organization.

(17) "External review decision" means a determination by an independent review organization at the conclusion of the external review.

(18) "Final internal adverse benefit determination" means an adverse benefit determination that has been upheld by a plan or issuer at the completion of the internal appeals process or when the internal appeals process has been deemed exhausted as defined in § 27-18.9-7(b)(1).

(19) "Health benefit plan" or "health plan" means a policy, contract, certificate, or agreement entered into, offered, or issued by a health care entity to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

(20) "Health care entity" means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, 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 health care services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or health care services.

(21) "Health care services" means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary's health benefit plan.

(22) "Independent review organization" or "IRO" means an entity that conducts independent external reviews of adverse benefit determinations or final internal adverse benefit determinations.

(23) "Network" means the group or groups of participating providers providing health care services under a network plan.

(24) "Network plan" means a health benefit plan or health plan that either requires a beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the providers managed, owned, under contract with, or employed by the health care entity.

(25) "Office" means the office of the health insurance commissioner.

(26) "Pre-service claim" means the request for a plan benefit(s) by a claimant prior to a service being rendered and is not considered a concurrent claim.

(27) "Professional provider" means an individual provider or health care professional licensed, accredited, or certified to perform specified health care services consistent with state law and who provides health care services and is not part of a separate facility or institutional contract.

(28) "Prospective assessment" and/or "pre-service assessment" mean an assessment of health care services prior to services being rendered.

(29) "Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.

(30) "Retrospective assessment" and/or "post-service assessment" means an assessment of health care services that have been rendered. This shall not include reviews conducted when the review agency has been obtaining ongoing information.

(31) "Retrospective claim" or "post-service claim" means any claim for a health plan benefit that is not a pre-service or concurrent claim.

(32) "Review agent" means a person or health care entity performing benefit determination reviews that is either employed by, affiliated with, under contract with, or acting on behalf of a health care entity.

(33) "Same or similar specialty" means a practitioner who has the appropriate training and experience that is the same or similar as the attending provider in addition to experience in treating the same problems to include any potential complications as those under review.

(34) "Therapeutic interchange" means the interchange or substitution of a drug with a dissimilar chemical structure within the same therapeutic or pharmacological class that can be expected to have similar outcomes and similar adverse reaction profiles when given in equivalent doses, in accordance with protocols approved by the president of the medical staff or medical director and the director of pharmacy.

(35) "Tiered network" means a network that identifies and groups some or all types of providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, or provider access requirements, or any combination thereof, apply for the same services.

(36) "Urgent health care services" includes those resources necessary to treat a symptomatic medical, mental health, substance use, or other health care condition that a prudent layperson, acting reasonably, would believe necessitates treatment within a twenty-four (24) hour period of the onset of such a condition in order that the patient's health status not decline as a consequence. This does not include those conditions considered to be emergent health care services as defined in in this section.

(37) "Utilization review" means the prospective, concurrent, or retrospective assessment of the medical necessity and/or appropriateness of the allocation of health care services of a provider, given or proposed to be given, to a beneficiary. Utilization review does not include:

(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a licensed inpatient health care facility; or

(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19 of title 5, and practicing in a pharmacy operating as part of a licensed inpatient health care facility, in the interpretation, evaluation and implementation of medical orders, including assessments and/or comparisons involving formularies and medical orders.

(38) "Utilization review plan" means a description of the standards governing utilization review activities performed by a review agent.

History of Section.
(P.L. 2017, ch. 302, art. 5, § 5.)