044-63 Wyo. Code R. §§ 63-3 - Definitions

(a) For purposes of this Rule:

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

(c) "Authorized representative" means:

(i) A person to whom a claimant has given express written consent to represent the claimant in an external review;

(ii) A person authorized by law to provide substituted consent for a claimant; or

(iii) A family member of the claimant or the claimant's treating health care professional only when the claimant is unable to provide consent.

(d) "Case management" means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.

(e) "Certification" means a determination by an insurer or its designee utilization review organization, or the claimant's treating health care professional that medical service has been reviewed and, based on the information provided, satisfies the statutory requirements for medical necessity as defined by W.S. § 26-40-102.

(f) "Claimant" means a policyholder, subscriber, enrollee or other individual participating in an insurance policy.

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

(h) "Commissioner" means the Commissioner of Insurance.

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

(j) "Denial of claim" means a determination by an insurer or its designee utilization review organization that a medical service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the requirements for medical necessity or other similar basis, and the requested service or payment for the service is therefore denied, reduced or terminated..

(k) "Insurance carrier" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that transacts the business of insurance as defined by W.S. § 26-1-102(a)(xv).

(l) "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.

(m) "Disclose" means to release, transfer or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information.

(n) "Emergency medical condition" means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy.

(o) "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition.

(p) "Facility" means an institution providing medical services or a health care setting, including but not limited to, hospitals and other licensed 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.

(q) "Insurance policy" means any contract, certificate, agreement, clauses, riders, and endorsements, offered or issued by an insurance carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(r) "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

(s) "Health care provider" or "provider" means a health care professional or a facility.

(t) "Health information" means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to:

(i) The past, present or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;

(ii) The provision of health care services to an individual; or

(iii) Payment for the provision of health care services to an individual.

(u) "Independent review organization" means an entity that conducts independent external reviews of claim denials.

(v) "Medical services" or "health care services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease or an admission, availability of care, continued stay or other care provided by a facility.

(w) "Medically necessary" includes but is not limited to "medical necessity" as defined by W.S. § 26-40-102(a)(iii).

(x) "NAIC" means the National Association of Insurance Commissioners.

(y) "Person" means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.

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

(aa) "Protected health information" means health information:

(i) That identifies an individual who is the subject of the information; or

(ii) With respect to which there is a reasonable basis to believe that the information could be used to identify an individual.

(bb) "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.

(cc) "Second opinion" means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service.

(dd) "Utilization review" means a set of formal techniques designed to monitor 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, or retrospective review.

(ee) "Utilization review organization" means an entity that conducts utilization review, other than an insurance carrier performing a review for its own insurance policies.

Notes

044-63 Wyo. Code R. §§ 63-3

Amended, Eff. 10/13/2015.