Utah Admin. Code R590-192-3 - Definitions

Terms used in this rule are defined in Sections 31A-1-301, 31A-22-629, and 29 CFR 2560.503-1(m). Additional terms are defined as follows:

(1) "Authorized agent" means an individual, corporation, association, organization, partnership, or other legal entity authorized to represent an insurer with respect to a claim.

(2) "Claim file" means a record that can accurately and reliably reproduce the original material regarding a claim, its investigation, adjustment, and settlement.

(3) "Claimant" means an insured or an insured's legal representative, including an immediate family member designated by the insured.

(4) "Concurrent care" or "ongoing care" means an insurer approves an ongoing course of treatment over a specific period or number of treatments.

(5) "Days" means calendar days.

(6) "Documentation" means a physical or an electronic record related to a claim.

(7) "General business practice" means a pattern of conduct in a business.

(8) "Investigation" means an activity of an insurer related to the determination of liability of a claim.

(9) "Medical necessity" means:

(a) a health care service or product that a prudent health care professional would provide to a patient to prevent, diagnose, or treat an illness, injury, disease, or its symptoms in a manner that is:

(i) in accordance with generally accepted standards of medical practice in the United States;

(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;

(iii) not primarily for the convenience of the patient, physician, or other health care provider; and

(iv) covered under the policy; and

(b) if a medical question-of-fact exists, "medical necessity" shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

(i) For an intervention not yet in widespread use, the effectiveness shall be based on scientific evidence.

(ii) For an established intervention, the effectiveness shall be based on:

(A) scientific evidence;

(B) professional standards; and

(C) expert opinion.

(10) "Misrepresentation" for a health benefit plan means an intentional misrepresentation of a material fact.

(11) "Notice of loss" means a claimant's notice that reasonably informs an insurer of the facts related to a claim.

(12) "Proof of loss" means a claimant's reasonable documentation in support of a claim.

(13)

(a) "Scientific evidence" means:

(i) a scientific study published or accepted by a medical journal that meets nationally recognized standards for a scientific manuscript and that submits its published articles for review by experts who are not part of the editorial staff; or

(ii) a finding, a study, or research conducted by or under the auspices of the federal government or a nationally recognized federal research institute.

(b) "Scientific evidence" does not include:

(i) published peer-reviewed literature sponsored by:

(A) a pharmaceutical manufacturing company; or

(B) a medical device manufacturer; or

(ii) a single study without other supportable studies.

Notes

Utah Admin. Code R590-192-3

Amended by Utah State Bulletin Number 2023-17, effective 8/22/2023