2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9393 - Definitions

For purposes of this chapter:
(a) Covered benefits or benefits.— Means those healthcare services to which a covered person or enrollee is entitled under the terms of a health plan.
(b) Certification.— Means a document that contains a determination by a health insurance organization or issuer, or a utilization review organization, that a request for a benefit under a health plan has been reviewed and, based on the information provided, satisfies the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care and effectiveness.
(c) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance organization or issuer to determine the medical necessity and appropriateness of healthcare services.
(d) Adverse determination.— Means:
(1) A determination by a health insurance organization or issuer, or a utilization review organization that, based upon the information provided, a request for a benefit under a health plan, upon application of any utilization review technique, does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness, or is determined to be experimental or investigational, and the requested benefit is therefore denied, reduced, or terminated, or payment is not provided or made, in whole or in part, for such benefit.
(2) the denial, reduction, termination, or failure to make payment, in whole or in part, for a benefit based on a determination by a health insurance organization or issuer, or a utilization review organization, of a covered person or enrollee's eligibility to participate in the health plan, or
(3) any prospective review or retrospective review determination that denies, reduces, or terminates, or fails to make payment, in whole or in part, for a benefit.
(e) Stabilized.— Means, with respect to an emergency medical condition, that no deterioration of the condition of the patient is likely, within reasonable medical probability, before the transfer of such individual from a facility.
(f) Clinical peer.— Means a physician or other healthcare professional who holds a non-restricted license in a state of the United States or in Puerto Rico, and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.
(g) Case management.— Means a coordinated set of activities established by a health insurance organization or issuer and conducted for individual patient management of serious, complicated, protracted, or other health conditions.
(h) Managed care clan.— Means:
(1) A health plan that requires a covered person or enrollee to use, or creates incentives, including financial incentives, for a covered person or enrollee to use healthcare providers managed, owned, under contract with, or employed by the health insurance organization or issuer.
(2) A managed care plan.— Includes:
(a) A preferred network plan, as defined in § 9002 of this title, and
(b) an open-ended plan, as defined in § 9002 of this title.
(i) Utilization review organization.— Means an entity contracted by a health insurance organization or issuer to conduct utilization review when such health insurance organization or issuer does not perform utilization review for its own health plan. It shall not be construed as a requirement for health insurance organizations or issuers to subcontract an independent entity to carry out utilization review processes.
(j) Health plan.— Means an insurance policy, contract, certificate, or agreement issued by a health insurance organization, healthcare service organization, or any other issuer, in exchange for the payment of premiums or on a prepaid basis, through which such health insurance organization, healthcare organization, or other issuer provides or pay for certain medical, hospital, major medical, dental, mental health, or incidental services.
(k) 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.
(l) Grievance.— Means a written complaint or an oral complaint if the complaint involves an urgent care request, submitted by or on behalf of a covered person or enrollee regarding:
(1) Availability, delivery, or quality of healthcare services, including complaints regarding an adverse determination made pursuant to utilization review;
(2) claims payment, handling, or reimbursement for healthcare services, or
(3) matters pertaining to the contractual relationship between a covered person or enrollee and a health insurance organization or issuer.
(m) Network.— Means the group of participating providers providing services to a managed care plan.
(n) Concurrent review.— Means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a healthcare professional, or other inpatient or outpatient healthcare setting.
(o) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(p) Utilization review.— Means a set of formal techniques designed to monitor healthcare services, procedures, or facilities or to evaluate the medical necessity, appropriateness, efficacy, or efficiency thereof. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.
(q) Prospective review.— Means utilization review conducted prior to the provision of a healthcare service or a course of treatment, in accordance with a health insurance organization or issuer's requirement that such healthcare service or course of treatment, in whole or in part, be approved prior to its provision.
(r) Retrospective review.— Means any review of a request for a benefit that is not a prospective review request. “Retrospective review” does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
(s) 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 healthcare service to assess the medical necessity and appropriateness of such initial proposed healthcare service.
(t) Urgent care request.— Means:
(1) A request for a healthcare service or course of treatment with respect to which the time period for making a non-urgent care request determination:
(A) Could seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or
(B) in the opinion of an attending healthcare professional with knowledge of the covered person or enrollee's medical condition, would subject said covered person or enrollee to severe pain that cannot be adequately managed without the healthcare service or treatment that is the subject of the request.
(2) In determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health insurance organization or issuer shall apply the judgment of a prudent layperson that possesses an average knowledge of health and medicine. Any request that an attending healthcare professional with knowledge of the covered person or enrollee's medical condition determines is an urgent care request within the meaning of clause (1) of this subsection shall be treated as an urgent care request.
History —Aug. 29, 2011, No. 194, § 22.030, eff. 180 days after Aug. 29, 2011.