02-031 C.M.R. ch. 850, § 5 - Definitions

For purposes of this rule:

A. "Adverse benefit determination" means any of the following, including but not limited to adverse health care treatment decisions: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including an action based on a determination of a participant's or beneficiary's ineligibility to participate in a plan.

DRAFTING NOTE:The term "adverse benefit determination" includes both adverse health care treatment (medical) decisions and adverse (non-medical) benefit determinations. Adverse health care treatment (medical) decisions are subject to section 8 of this rule. Adverse (non-medical) benefit determinations are subject to section 9 of this rule. All adverse benefit determinations are subject to section 10 of this rule.

A-1. "Adverse health care treatment decision" means a health care treatment decision made by or on behalf of a carrier offering a health plan denying in whole or in part payment for or provision of otherwise covered services requested by or on behalf of an enrollee. "Health care treatment decision" means a decision regarding diagnosis, care, or treatment when medical services are provided by a health plan, or a benefits decision involving determinations regarding medically necessary health care, preexisting condition determinations and determinations regarding experimental or investigational services. "Adverse health care treatment decision" includes a rescission determination and an initial coverage eligibility determination, consistent with the requirements of the federal Affordable Care Act.

B. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.

C. "Ancillary Services" means appropriately licensed ancillary non-physician services which may include but are not limited to home health care, durable medical equipment, physical therapy, chiropractic, podiatry, certified nurse midwifery, pharmacy, home care, alcohol and chemical dependency services, and mental health services provided by psychologists, social workers, counseling professionals and psychiatric nurses in inpatient, outpatient treatment and residential treatment settings, as appropriate in each case. The listing of a particular service or category of provider in this definition does not function to mandate that coverage for that service or category of provider is required.

D. "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, or attending physician, facility or health care provider on a covered person's behalf, can contest an adverse health care treatment decision rendered by the health carrier or its designee utilization review entity (URE), which results in the denial, reduction without further opportunity for additional services or termination of coverage of a requested health care service.

E. "Carrier" or "health carrier" means:

1) An insurance company licensed in accordance with Title 24-A to provide health insurance;

2) A health maintenance organization licensed pursuant to Title 24-A Chapter 56;

3) A preferred provider arrangement administrator registered pursuant to Title 24-A Chapter 32;

4) A fraternal benefit society, as defined by 24-A M.R.S.A. §4101;

5) A nonprofit hospital or medical service organization or health plan licensed pursuant to Title 24;

6) A multiple-employer welfare arrangement licensed pursuant to 24-A M.R.S.A. Chapter 81;

7) A self-insured employer subject to state regulation as described in 24-A M.R.S.A. §2848-A; or

8) Notwithstanding any other provision of Title 24-A, an entity offering coverage in this State that is subject to the requirements of the federal Affordable Care Act.

An employer exempted from the applicability of 24-A M.R.S.A. Chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) is not considered a carrier.

F. "Case management" means a coordinated set of activities conducted for individual patient management of covered persons with specific health care needs.

G. "Certification" means a determination by a health carrier or its designee utilization review entity (URE) that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.

H. "Clinical peer" means a physician or other licensed health care practitioner who holds a non-restricted license in a state of the United States, is board certified in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, and whose compensation does not depend, directly or indirectly, upon the quantity, type, or cost of the medical condition, procedure, or treatment that the practitioner approves or denies on behalf of a carrier.

I. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the necessity and appropriateness of health care services.

J. [REPEALED]

K. "Concurrent review" means utilization review conducted during a patient's hospital stay or course of treatment.

L. "Covered benefits" or "benefits" means those health care services a covered person is entitled to have paid, in whole or in part, under the terms of a health benefit plan.

M. "Covered person" means a policyholder, subscriber, enrollee or other individual entitled to benefits under a health benefit plan.

M-1. "Designated Provider" means any health care provider that has been identified so that a covered person may receive incentives for obtaining services from the designated provider that differ from the incentives generally available for obtaining services from a network provider. A designated provider does not have to be a network provider within the plan's service area. A designated provider may be identified as a member of a class (for example, through a rating system), or may be identified by name. A designated provider may be designated either in advance or at the time an enrollee requests services.

N. "Discharge planning" means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.

O. "Emergency medical condition" means the sudden and, at the time, unexpected onset of a physical or mental health condition, including severe pain, manifesting itself by symptoms of sufficient severity, regardless of the final diagnosis that is given, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe:

1) that the absence of immediate medical attention could reasonably be expected to result in:

a) placing the physical or mental 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 of a bodily function; or

c) serious dysfunction of any organ or body part; or,

2) with respect to a pregnant woman who is having contractions, that there is:

a) inadequate time to effect a safe transfer of the woman to another hospital before delivery, or,

b) a threat to the health or safety of the woman or unborn child if the woman were to be transferred to another hospital.

P. "Emergency service" means a health care item or service, furnished or required to evaluate and treat an emergency medical condition, that is provided in an emergency facility or setting.

Q. "Essential Community Provider" includes, but is not limited to, the following, consistent with the requirements of federal law:

1) Federally-qualified health centers as defined in section 1861 (aa) of the Social Security Act;

2) nonprofit maternal and child health providers that receive funding for their services under Title V of the Social Security Act;

3) Indian health programs under the Indian Health Care Improvement Act; and

4) health care service provider recipients or sub recipients of grants under Title X, Title XIX, Title XXIII or sections 329, 330, 340, 340 A, of the Public Health Service Act.

Q-1. "Exigent circumstances" exist when a covered person is suffering from a health condition that may seriously jeopardize the covered person's life, health or ability to regain maximum function or when a covered person is undergoing a current course of treatment using a non formulary drug.

R. "Facility" means an institution providing health care services or a health care setting, including but not limited to appropriately licensed or certified hospitals and other 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.

S. "Grievance" means a written complaint submitted by or on behalf of a covered person regarding:

DRAFTING NOTE: Written complaints include complaints sent via e-mail.

1) The availability, delivery or quality of health care services, including a complaint regarding an adverse health care treatment decision made pursuant to utilization review;

2) Claims payment, handling or reimbursement for health care services;

3) Matters pertaining to the contractual relationship between a covered person and a health carrier; or

4) Adverse benefit determinations.

S-1. "Grievance procedure" means a formal process whereby a covered person or a representative of a covered person can contest an adverse benefit determination.

DRAFTING NOTE:Because "adverse benefit determinations" include adverse medical decisions as well as adverse non-medical determinations, the term "grievance procedure" includes the procedures for review of both medical and non-medical determinations.

T. "Health plan" or "health benefit plan" means a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan, other than a plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefit coverage not subject to the requirements of the federal Affordable Care Act. A plan that is subject to the requirements of the federal Affordable Care Act and offered in this State by a carrier, including, but not limited to, a qualified health plan offered on an American Health Benefit Exchange or a SHOP Exchange established pursuant to the federal Affordable Care Act, is a health plan for purposes of this rule.

U. "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law. This definition applies to individual health professionals, not corporate "persons."

V. "Health care provider" or "provider" means a practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law.

W. "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease including mental illness and alcohol and chemical dependency.

X. "Health carrier." See definition of "carrier" at subsection 5(E).

Y. "Managed care plan" means a health benefit plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan through:

1) arrangements with selected providers to furnish health care services; and

2) financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan. A return to work program developed for the management of workers' compensation claims may not be considered a managed care plan.

Z. "Network" means the group of participating providers providing services to a managed care plan.

AA. [REPEALED]

BB. "Participating provider" means a licensed or certified provider of health care services, including mental health services, or health care supplies that has entered into an agreement with a carrier to provide those services or supplies to an individual enrolled in a managed care plan.

CC. "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a limited liability company, a trust, an unincorporated organization, any similar entity, any affiliate of these entities or any combination of the foregoing.

DD. "Physician" means a duly licensed doctor of medicine or osteopathy practicing within the scope of a license.

EE. "Primary care" means initial and basic care, and includes general internal medicine, general pediatrics, general obstetrics and gynecology, and care customarily provided by general and family practitioners or OB/GYNs.

FF. "Primary care provider" means a physician, or a nurse practitioner or physician assistant under the supervision of a physician, under contract with a managed care plan to supervise, coordinate, and provide initial and basic care to plan enrollees, maintain continuity of patient enrollee care, and initiate patient enrollee referrals for specialist care.

GG. "Primary verification" means verification of a health professional's credentials based upon evidence obtained from the issuing source of the credentials.

HH. "Prospective review" means utilization review conducted prior to an admission or a course of treatment.

II. "Retrospective review" means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.

JJ. "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by an appropriately licensed or certified provider, other than the provider making the initial recommendation for a proposed health service, to assess the clinical necessity and appropriateness of the initially proposed health service.

KK. "Secondary verification" means verification of a health professional's credentials based upon evidence obtained by means other than direct contact with the issuing source of the credential (e.g., copies of certificates provided by the applying health professional).

LL. "Service Area" means the area lying within the geographic perimeters of an approved managed care plan health care network.

MM. "Special Needs" means individuals who have mental retardation, mental illness, behavioral and/or emotional disturbances and developmental delays and disabilities, requiring coordinated health care services. Individuals with special needs may include but are not limited to individuals diagnosed with schizophrenia, bipolar disorder, pervasive developmental disorder or autism, paranoia, panic disorder, obsessive-compulsive disorder, major depressive disorder, attention deficit disorder, and/or conduct disorder or physical impairments of chronic duration such that an individual so diagnosed cannot function effectively in home, school or community settings without coordinated health care services.

NN. "Specialty Physician Services" means general physician services beyond primary care.

OO. "Stabilized" means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result or occur before an individual can be transferred.

PP. "Superintendent" means the Superintendent of Insurance.

QQ. "Urgent Services" or "Urgent Care" means medical care or treatment provided in response to exigent circumstances.

RR. "Utilization review" means any program or practice by which a person, on behalf of an insurer, nonprofit service organization, 3rd-party administrator or employer, which is a payor for or which arranges for payment of medical services, seeks to review the utilization, clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures, providers or facilities. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Decisions regarding medical necessity made by a covered person's primary care provider do not constitute utilization review.

SS. "Utilization review entity (URE) means an entity that conducts utilization review, other than a health carrier performing review for its own health plans.

Notes

02-031 C.M.R. ch. 850, § 5