2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9503 - Definitions

For purposes of this chapter:
(a) Certification.— Means a document that contains a determination by a health insurance organization or issuer or its designee utilization review organization that the request for healthcare service or the healthcare service provided has been reviewed and, based on the information furnished, such service is covered by the health plan and satisfies the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care and effectiveness.
(b) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a health insurance organization or issuer to determine the necessity and appropriateness of healthcare services.
(c) Adverse determination.— Means a determination by a health insurance organization or issuer or its designee utilization review organization that based upon the information provided, a request for service or benefit under the health plan does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness, or its determined to be experimental or investigational and the request for service or benefit is therefore denied, reduced or terminated or payment is not provided, in whole or in part, for such service or benefit.
(d) Final adverse determination.— Means an adverse determination involving a covered benefit that has been upheld by a health insurance organization or issuer, or its designee utilization review organization, at the completion of the health insurance organization or issuer's internal grievance process procedures as set forth in §§ 9391–9400 of this title.
(e) Disclose.— Means to release, transfer or otherwise divulge protected health information to any person other than the individual who is the subject of such information.
(f) Medical or scientific evidence.— Means evidence found in the following sources:
(1) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts.
(2) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE).
(3) Medical journals recognized by the United States Secretary of Health and Human Services pursuant to the Federal Social Security Act.
(4) The following standard reference compendia:
(A) The American Hospital Formulary Service-Drug Information; Therapeutics; and
(B) Drug Facts and Comparisons®;
(C) The American Dental Association Accepted Dental
(D) The United States Pharmacopoeia-Drug Information;
(5) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(A) The Federal Agency for Healthcare Research and Quality;
(B) The National Institutes of Health;
(C) The National Cancer Institute;
(D) The National Academy of Sciences;
(E) The Centers for Medicare & Medicaid Services (CMS);
(F) The Federal Food and Drug Administration (FDA); and
(G) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of healthcare services; or
(6) Any other medical or scientific evidence that is comparable to the sources listed in clauses (1)–(5) of this subsection.
(g) 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:
(1) The past, present or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;
(2) the provision of healthcare services to an individual, or
(3) payment for the provision of healthcare services to an individual.
(h) Protected health information.— Means health information:
(1) That identifies an individual who is the subject of the information, or
(2) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
(i) Case management.— Means a coordinated set of activities established by the health insurance organization or issuer conducted for individual patient management of complicated, protracted or other health conditions.
(j) Utilization review organization.— Means an entity contracted to conduct utilization reviews, other than a health insurance organization or issuer performing a review for its own health plans. It shall not be construed as a requirement for a health insurance organization or issuer to subcontract an independent entity to conduct the utilization review process.
(k) Independent review organization.— Means an entity that conducts independent external reviews of adverse determinations and final adverse determinations issued by a health insurance organization or issuer, or its designee utilization review organization.
(l) Discharge planning.— Means the formal process for determining, prior to discharge from a healthcare facility, the coordination and management of the care that a patient receives following discharge from a facility.
(m) Concurrent review.— Means utilization review conducted during a patient's stay or course of treatment in a healthcare facility, the office of a healthcare professional, or other inpatient or outpatient healthcare setting.
(n) Ambulatory review.— Means utilization review of healthcare services performed or provided in an outpatient setting.
(o) 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.
(p) 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.
(q) 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.
(r) 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 the initial proposed healthcare service.
History —Aug. 29, 2011, No. 194, added as § 28.030 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.