2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9423 - Definitions

For purposes of this chapter:
(a) Certification.— Means a document containing a determination by a health insurance organization or issuer or utilization review organization that a request for a benefit under the health insurance organization or issuer's 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.
(b) Emergency medical condition.— Means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that would lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably expect that the absence of immediate medical attention would place an individual's health in serious jeopardy; or result in serious dysfunction of a bodily organ or part; or with respect to a pregnant woman who is having contractions, the lack of sufficient time to transfer her to other facilities before delivery, or that her transfer would result in serious jeopardy to her health or the health of her unborn child.
(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 utilization review organization that a requested benefit is denied, reduced or terminated or payment is not made, in whole or in part, for the benefit upon application of any utilization review technique, based upon the information provided, the requested benefit, according to the health plan does not meet the requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness or is determined to be experimental or investigational;
(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 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 material deterioration of the condition is likely, within reasonable medical probability, to result from the transfer of the patient.
(f) Clinical peer.— Means a physician or other healthcare professional who holds a nonrestricted license in a state of the United States or in Puerto Rico and in the same or similar specialty as the physicians or healthcare professionals who typically manage the medical condition, procedure or treatment under review.
(g) Case management.— Means a coordinated set of activities established by the health insurance organization or issuer, conducted for individual patient management of serious, complicated, protracted, or other health conditions.
(h) Utilization review organization.— Means an entity contracted by a health insurance organization or issuer to conduct utilization review, other than a health insurance organization or issuer performing utilization review for its own health plans. It shall not be construed as a requirement for the health insurance organization or issuer to subcontract a utilization review organization to conduct its utilization review processes.
(i) 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.
(j) 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.
(k) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(l) Utilization review.— Means a set of formal techniques designed to monitor healthcare services, procedures, or settings in which such services are provided, 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.
(m) 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 the healthcare service or course of treatment, in whole or in part, be approved prior to its provision.
(n) Retrospective review.— Means any review of a request for a benefit that is carried out after the healthcare service is provided. Retrospective review does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
(o) 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 service.
(p) Emergency services.— Means healthcare services provided or required to treat an emergency medical condition.
(q) Urgent care request.— Means:
(1) A request for a healthcare service or course of treatment with respect to which the time periods 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 a physician with knowledge of the covered person or enrollee's medical condition, would subject the covered person or enrollee to severe pain that cannot be adequately managed without the healthcare service or treatment requested.
(2) In determining whether a request is 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 who possesses an average knowledge of health and medicine. Any request that a physician 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 by the health insurance organization or issuer.
History —Aug. 29, 2011, No. 194, added as § 24.030 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.