Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.020 - Definitions

Current through Register 1525, July 5, 2024
As used in
				958 CMR
				3.000 the following words shall have the following
				meanings:
Actively Practicing
means that a
				health care professional regularly treats patients in a clinical
				setting.
Adverse Determination
means a
				determination, based upon a review of information provided, by a carrier or its
				designated utilization review organization, to deny, reduce, modify, or
				terminate an admission, continued inpatient stay, or the availability of any
				other health care services, for failure to meet the requirements for coverage
				based on medical necessity, appropriateness of health care setting and level of
				care, or effectiveness, including a determination that a requested or
				recommended health care service or treatment is experimental or
				investigational.
Authorized Representative
means an
				insured's guardian, conservator, holder of a power of attorney, health care
				agent designated pursuant to M.G.L. c. 210, family member, or other person
				authorized by the insured in writing or by law with respect to a specific
				grievance or external review, provided that if the insured is unable to
				designate a representative, where such designation would otherwise be required,
				a guardian, conservator, holder of a power of attorney, or family member in
				that order of priority may be the insured's representative or may appoint
				another responsible party to serve as the insured's authorized representative.
				If the authorized representative is a health care provider, the insured must
				specify a named individual who will act on behalf of the authorized
				representative and a telephone number for that individual.
Carrier
means an insurer licensed, or
				otherwise authorized to transact accident or health insurance under M.G.L.
				c.175; a nonprofit hospital service corporation organized under M.G.L. c. 176A;
				a nonprofit medical service corporation organized under M.G.L. c. 176B; a
				health maintenance organization organized under M.G.L. c. 176G; and an
				organization entering into a preferred provider arrangement under M.G.L. c.
				1761, but not including an employer purchasing coverage or acting on behalf of
				its employees or the employees of one or more subsidiaries or affiliated
				corporations of the employer. Carrier shall not include any entity to the
				extent it offers a policy, certificate or contract that provides coverage
				solely for dental care services or vision care services.
Clinical Review Criteria
means the
				written screening procedures, decisions, abstracts, clinical protocols and
				practice guidelines used by a carrier to determine the medical necessity and
				appropriateness of health care services.
Commission
means the Health Policy
				Commission.
Complaint
means:
(a) any inquiry made by or on behalf of an
			 insured to a carrier or utilization review organization that is not explained
			 or resolved to the insured's satisfaction within three business days of the
			 inquiry; or
(b) any matter
			 concerning an adverse determination. In the case of a carrier or utilization
			 review organization that does not have an internal inquiry process, a complaint
			 means any inquiry.
Covered Benefits or Benefits
means
				health care services to which an insured is entitled under the terms of the
				health benefit plan.
Days
means calendar days, unless
				otherwise specified.
Evidence of Coverage
means any
				certificate, contract or agreement of health insurance including riders,
				amendments, endorsements and any other supplementary inserts or a summary plan
				description pursuant to § 104(b)(1) of the Employee Retirement Income
				Security Act of 1974, 29
				U.S.C. §
										1024(b),
				issued to an insured specifying the benefits to which the insured is
				entitled.
External Review Agency
means an
				independent review organization, which is an entity or company under contract
				with the Commission to conduct independent reviews of adverse determinations
				pursuant to M.G.L. c. 1760. Each external review agency shall be accredited by
				a national accrediting organization.
Facility
means a licensed 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.
Final Adverse Determination
means an
				adverse determination made after an insured has exhausted all remedies
				available through a carrier's formal internal grievance process.
Financial Affiliation or Financial
				Relationship
means any financial interest in a carrier provided
				that the term financial affiliation shall not include revenue received from a
				carrier by a clinical reviewer for health services rendered to insureds.
Grievance
means any oral or written
				complaint submitted to the carrier that has been initiated by an insured, or
				the insured's authorized representative, concerning any aspect or action of the
				carrier relative to the insured, including, but not limited to, review of
				adverse determinations regarding scope of coverage, denial of services,
				rescission of coverage, quality of care and administrative operations, in
				accordance with the requirements of
				958 CMR 3.000.
Health Benefit Plan
means a policy,
				contract, certificate or agreement entered into, offered or issued by a carrier
				to provide, deliver, arrange for, pay for, or reimburse any of the costs of
				health care services.
Health Care Professional
means a
				physician or other health care practitioner licensed, accredited or certified
				to perform specified health services consistent with law.
Health Care Provider or Provider
means
				a health care professional or facility.
Health Care Services
means services
				for the diagnosis, prevention, treatment, cure or relief of a health condition,
				illness, injury or disease.
Inquiry
means any communication by or
				on behalf of an insured to the carrier or utilization review organization that
				has not been the subject of an adverse determination and that requests redress
				of an action, omission or policy of the carrier.
Insured
means an enrollee, covered
				person, insured, member, policy holder or subscriber of a carrier, including an
				individual whose eligibility as an insured of a carrier is in dispute or under
				review, or any other individual whose care may be subject to review by a
				utilization review program or entity as described under the provisions of
				M.G.L. c. 176O,
				211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
				Carriers
and
				958 CMR 3.000.
Material Familial Affiliation
means
				any relationship as a spouse, child, parent, sibling, spouse's parent, spouse's
				child, child's parent, child's spouse, sibling's spouse, domestic partner,
				aunt, uncle, foster parent or foster child.
Material Professional Affiliation
means any any health care professional-patient relationship, any partnership or
				employment relationship, a shareholder or similar ownership interest in a
				professional corporation, or any independent contractor arrangement that
				constitutes a financial affiliation.
Medical Necessity or Medically
				Necessary
means health care services that are consistent with
				generally accepted principles of professional medical practice as determined by
				whether the service:
(a) is the most
			 appropriate available supply or level of service for the insured in question
			 considering potential benefits and harms to the individual;
(b) is known to be effective, based on
			 scientific evidence, professional standards and expert opinion, in improving
			 health outcomes; or
(c) for services
			 and interventions not in widespread use, is based on scientific evidence.
Office of Patient Protection
means the
				office within the Commission established by M.G.L. c. 6D, § 16.
Participating Provider
means a
				provider who, under a contract with the carrier or with its contractor or
				subcontractor, has agreed to provide health care services to insureds with an
				expectation of receiving payment, other than coinsurance, copayments or
				deductibles, directly or indirectly from the carrier.
Primary Care Provider
means a health
				care professional qualified to provide general medical care for common health
				care problems, who supervises, coordinates, prescribes, or otherwise provides
				or proposes health care services, initiates referrals for specialist care, and
				maintains continuity of care within the scope of his or her practice.
Same or Similar Specialty
means that
				the health care professional has similar credentials and licensure as those who
				typically provide the treatment in question and has experience treating the
				same condition that is the subject of the grievance. Such experience shall
				extend to the treatment of children in a grievance involving a child where the
				age of the patient is relevant to the determination of whether a requested
				service or supply is medically necessary.
Service Area
means the geographical
				area as approved by the Commissioner of Insurance within which the carrier has
				developed a network of providers to afford adequate access to members for
				covered health services.
Terminal Illness
means an illness that
				is likely, within a reasonable degree of medical certainty, to cause one's
				death within six months, or as otherwise defined in § 1861(dd)(3)(A) of
				the Social Security Act (42 U.S.C.
				1395x(dd)(3)(A)).
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. Such techniques may include, but are not limited to,
				ambulatory review, prospective review, second opinion, certification,
				concurrent review, case management, discharge planning or retrospective
				review.
Utilization Review Organization
means
				an entity that conducts utilization review under contract with or on behalf of
				a carrier, but does not include a carrier performing utilization review for its
				own health benefit plans.