Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.02 - Definitions

Current through June 25, 2024
For purposes of this Regulation:
A. "Adverse determination" means a determination by a health
				  carrier or its designee utilization review organization that an admission,
				  availability of care, continued stay or other health care service that is a
				  covered benefit has been reviewed and, based upon the information provided,
				  does not meet the health carrier's requirements for medical necessity,
				  appropriateness, health care setting, level of care or effectiveness, and the
				  requested service or payment for the service is therefore denied, reduced or
				  terminated.
B. "Ambulatory review" means utilization review of health
				  care services performed or provided in an outpatient setting.
C. "Authorized representative" means:
1. A person to whom a covered person has given express
				  written consent to represent the covered person in an external review;
2. A person authorized by law to provide substituted consent
				  for a covered person; or
3. A family member of the covered person or the covered
				  person's treating health care professional only when the covered person is
				  unable to provide consent.
D. "Best evidence" means evidence based on:
1. Randomized clinical trials;
2. If randomized clinical trials are not available, cohort
				  studies or case-control studies;
3. If paragraphs (1) and (2) are not available, case-series;
				  or
4. If paragraphs (1), (2) and (3) are not available, expert
				  opinion.
E. "Case-control study" means a retrospective evaluation of
				  two (2) groups of patients with different outcomes to determine which specific
				  interventions the patients received.
F. "Case management" means a coordinated set of activities
				  conducted for individual patient management of serious, complicated, protracted
				  or other health conditions.
G. "Case-series" means an evaluation of a series of patients
				  with a particular outcome, without the use of a control group.
H. "Certification" means a determination by a health carrier
				  or its designee utilization review organization that an admission, availability
				  of care, continued stay or other health care service has been reviewed and,
				  based on the information provided, satisfies the health carrier's requirements
				  for medical necessity, appropriateness, health care setting, level of care and
				  effectiveness.
I. "Clinical review criteria" means the written screening
				  procedures, decision abstracts, clinical protocols and practice guidelines used
				  by a health carrier to determine the necessity and appropriateness of health
				  care services.
J. "Cohort study" means a prospective evaluation of two (2)
				  groups of patients with only one group of patients receiving a specific
				  intervention(s).
K. "Commissioner" means the Commissioner of Insurance.
L. "Concurrent review" means utilization review conducted
				  during a patient's hospital stay or course of treatment.
M. "Covered benefits" or "benefits" means those health care
				  services to which a covered person is entitled under the terms of a health
				  benefit plan.
N. "Covered person" means a policyholder, subscriber,
				  enrollee or other individual participating in a health benefit plan.
O. "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.
P. "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.
Q. "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.
R. "Emergency services" means health care items and services
				  furnished or required to evaluate and treat an emergency medical
				  condition.
S. "Evidence-based standard" means the conscientious,
				  explicit and judicious use of the current best evidence based on the overall
				  systematic review of the research in making decisions about the care of
				  individual patients.
T. "Expert opinion" means a belief or an interpretation by
				  specialists with experience in a specific area about the scientific evidence
				  pertaining to a particular service, intervention or therapy.
U. "Facility" means an institution providing health care
				  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.
V. "Final adverse determination" means an adverse
				  determination involving a covered benefit that has been upheld by a health
				  carrier, or its designee utilization review organization, at the completion of
				  the health carrier's internal grievance process procedures.
W. "Health benefit plan" means a policy, contract,
				  certificate or agreement offered or issued by a health carrier to provide,
				  deliver, arrange for, pay for or reimburse any of the costs of health care
				  services.
X. "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.
Y. "Health care provider" or "provider" means a health care
				  professional or a facility.
Z. "Health care services" means services for the diagnosis,
				  prevention, treatment, cure or relief of a health condition, illness, injury or
				  disease.
AA. "Health carrier" means an entity subject to the insurance
				  laws and regulations of this State, or subject to the jurisdiction of the
				  Commissioner, that contracts or offers to contract to provide, deliver, arrange
				  for, pay for or reimburse any of the costs of health care services, including a
				  sickness and accident insurance company, a health maintenance organization, a
				  nonprofit hospital and health service corporation, or any other entity
				  providing a plan of health insurance, health benefits or health care
				  services.
BB. "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 health care services to an individual;
				  or
3. Payment for the provision of health care services to an
				  individual.
CC. "Independent review organization" means an entity that
				  conducts independent external reviews of adverse determinations and final
				  adverse determinations.
DD. "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 and that submit most of their published
				  articles for review by experts who are not part of the editorial staff;
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 Secretary of Health and
				  Human Services under Section 1861(t)(2) of the federal Social Security
				  Act;
4. The following standard reference compendia:
a. The American Hospital Formulary Service-Drug
				  Information;
b. Drug Facts and Comparisons;
c. The American Dental Association Accepted Dental
				  Therapeutics; and 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;
f. The federal Food and Drug Administration; and
g. Any national board recognized by the National Institutes
				  of Health for the purpose of evaluating the medical value of health care
				  services; or
6. Any other medical or scientific evidence that is
				  comparable to the sources listed in paragraphs (1) through (5).
EE. "NAIC" means the National Association of Insurance
				  Commissioners.
FF. "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.
GG. "Prospective review" means utilization review conducted
				  prior to an admission or a course of treatment.
HH. "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.
II. "Randomized clinical trial" means a controlled,
				  prospective study of patients that have been randomized into an experimental
				  group and a control group at the beginning of the study with only the
				  experimental group of patients receiving a specific intervention, which
				  includes study of the groups for variables and anticipated outcomes over
				  time.
JJ. "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.
KK. "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.
LL. "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.
MM. "Utilization review organization" means an entity that
				  conducts utilization review, other than a health carrier performing a review
				  for its own health benefit plans.
Miss. Code Ann. §
										83-5-1
				  (Rev. 2011); Public Law
				  111-148 -Mar. 23, 2010 (Patient Protection and
				  Affordable Care Act)