376.1350. Definitions.
Definitions.
376.1350. For purposes of sections 376.1350 to 376.1390, the followingterms mean:
(1) "Adverse determination", a determination by a health carrier or itsdesignee utilization review organization that an admission, availability ofcare, continued stay or other health care service has been reviewed and, basedupon the information provided, does not meet the health carrier's requirementsfor medical necessity, appropriateness, health care setting, level of care oreffectiveness, and the payment for the requested service is therefore denied,reduced or terminated;
(2) "Ambulatory review", utilization review of health care servicesperformed or provided in an outpatient setting;
(3) "Case management", a coordinated set of activities conducted forindividual patient management of serious, complicated, protracted or otherhealth conditions;
(4) "Certification", a determination by a health carrier or its designeeutilization review organization that an admission, availability of care,continued stay or other health care service has been reviewed and, based onthe information provided, satisfies the health carrier's requirements formedical necessity, appropriateness, health care setting, level of care andeffectiveness;
(5) "Clinical peer", a physician or other health care professional whoholds a nonrestricted license in a state of the United States and in the sameor similar specialty as typically manages the medical condition, procedure ortreatment under review;
(6) "Clinical review criteria", the written screening procedures,decision abstracts, clinical protocols and practice guidelines used by thehealth carrier to determine the necessity and appropriateness of health careservices;
(7) "Concurrent review", utilization review conducted during a patient'shospital stay or course of treatment;
(8) "Covered benefit" or "benefit", a health care service that anenrollee is entitled under the terms of a health benefit plan;
(9) "Director", the director of the department of insurance, financialinstitutions and professional registration;
(10) "Discharge planning", the formal process for determining, prior todischarge from a facility, the coordination and management of the care that apatient receives following discharge from a facility;
(11) "Drug", any substance prescribed by a licensed health care provideracting within the scope of the provider's license and that is intended for usein the diagnosis, mitigation, treatment or prevention of disease. The termincludes only those substances that are approved by the FDA for at least oneindication;
(12) "Emergency medical condition", the sudden and, at the time,unexpected onset of a health condition that manifests itself by symptoms ofsufficient severity that would lead a prudent lay person, possessing anaverage knowledge of medicine and health, to believe that immediate medicalcare is required, which may include, but shall not be limited to:
(a) Placing the person's health in significant jeopardy;
(b) Serious impairment to a bodily function;
(c) Serious dysfunction of any bodily organ or part;
(d) Inadequately controlled pain; or
(e) With respect to a pregnant woman who is having contractions:
a. That there is inadequate time to effect a safe transfer to anotherhospital before delivery; or
b. That transfer to another hospital may pose a threat to the health orsafety of the woman or unborn child;
(13) "Emergency service", a health care item or service furnished orrequired to evaluate and treat an emergency medical condition, which mayinclude, but shall not be limited to, health care services that are providedin a licensed hospital's emergency facility by an appropriate provider;
(14) "Enrollee", a policyholder, subscriber, covered person or otherindividual participating in a health benefit plan;
(15) "FDA", the federal Food and Drug Administration;
(16) "Facility", an institution providing health care services or ahealth care setting, including but not limited to hospitals and other licensedinpatient centers, ambulatory surgical or treatment centers, skilled nursingcenters, residential treatment centers, diagnostic, laboratory and imagingcenters, and rehabilitation and other therapeutic health settings;
(17) "Grievance", a written complaint submitted by or on behalf of anenrollee regarding the:
(a) Availability, delivery or quality of health care services, includinga complaint regarding an adverse determination made pursuant to utilizationreview;
(b) Claims payment, handling or reimbursement for health care services;or
(c) Matters pertaining to the contractual relationship between anenrollee and a health carrier;
(18) "Health benefit plan", a policy, contract, certificate or agreemententered into, offered or issued by a health carrier to provide, deliver,arrange for, pay for, or reimburse any of the costs of health care services;except that, health benefit plan shall not include any coverage pursuant toliability insurance policy, workers' compensation insurance policy, or medicalpayments insurance issued as a supplement to a liability policy;
(19) "Health care professional", a physician or other health carepractitioner licensed, accredited or certified by the state of Missouri toperform specified health services consistent with state law;
(20) "Health care provider" or "provider", a health care professional ora facility;
(21) "Health care service", a service for the diagnosis, prevention,treatment, cure or relief of a health condition, illness, injury or disease;
(22) "Health carrier", an entity subject to the insurance laws andregulations of this state that contracts or offers to contract to provide,deliver, arrange for, pay for or reimburse any of the costs of health careservices, including a sickness and accident insurance company, a healthmaintenance organization, a nonprofit hospital and health service corporation,or any other entity providing a plan of health insurance, health benefits orhealth services; except that such plan shall not include any coverage pursuantto a liability insurance policy, workers' compensation insurance policy, ormedical payments insurance issued as a supplement to a liability policy;
(23) "Health indemnity plan", a health benefit plan that is not amanaged care plan;
(24) "Managed care plan", a health benefit plan that either requires anenrollee to use, or creates incentives, including financial incentives, for anenrollee to use, health care providers managed, owned, under contract with oremployed by the health carrier;
(25) "Participating provider", a provider who, under a contract with thehealth carrier or with its contractor or subcontractor, has agreed to providehealth care services to enrollees with an expectation of receiving payment,other than coinsurance, co-payments or deductibles, directly or indirectlyfrom the health carrier;
(26) "Peer-reviewed medical literature", a published scientific study ina journal or other publication in which original manuscripts have beenpublished only after having been critically reviewed for scientific accuracy,validity and reliability by unbiased independent experts, and that has beendetermined by the International Committee of Medical Journal Editors to havemet the uniform requirements for manuscripts submitted to biomedical journalsor is published in a journal specified by the United States Department ofHealth and Human Services pursuant to Section 1861(t)(2)(B) of the SocialSecurity Act, as amended, as acceptable peer-reviewed medical literature.Peer-reviewed medical literature shall not include publications or supplementsto publications that are sponsored to a significant extent by a pharmaceuticalmanufacturing company or health carrier;
(27) "Person", an individual, a corporation, a partnership, anassociation, a joint venture, a joint stock company, a trust, anunincorporated organization, any similar entity or any combination of theforegoing;
(28) "Prospective review", utilization review conducted prior to anadmission or a course of treatment;
(29) "Retrospective review", utilization review of medical necessitythat is conducted after services have been provided to a patient, but does notinclude the review of a claim that is limited to an evaluation ofreimbursement levels, veracity of documentation, accuracy of coding oradjudication for payment;
(30) "Second opinion", an opportunity or requirement to obtain aclinical evaluation by a provider other than the one originally making arecommendation for a proposed health service to assess the clinical necessityand appropriateness of the initial proposed health service;
(31) "Stabilize", with respect to an emergency medical condition, thatno material deterioration of the condition is likely to result or occur beforean individual may be transferred;
(32) "Standard reference compendia":
(a) The American Hospital Formulary Service-Drug Information; or
(b) The United States Pharmacopoeia-Drug Information;
(33) "Utilization review", a set of formal techniques designed tomonitor the use of, or evaluate the clinical necessity, appropriateness,efficacy, or efficiency of, health care services, procedures, or settings.Techniques may include ambulatory review, prospective review, second opinion,certification, concurrent review, case management, discharge planning orretrospective review. Utilization review shall not include elective requestsfor clarification of coverage;
(34) "Utilization review organization", a utilization review agent asdefined in section 374.500, RSMo.
(L. 1997 H.B. 335, A.L. 2002 H.B. 1468 merged with H.B. 1473)