Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 216 - RULES GOVERNING INTERNAL APPEAL AND EXTERNAL REVIEW › Part I - General › Section 14VAC5-216-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"Adverse benefit determination" in the context of the
					 internal appeals process means
(i)  a determination by a health carrier or its designee
					 utilization review entity that, based on the information provided, a request
					 for, a benefit under the health carrier's health benefit plan upon application
					 of any utilization review technique does not meet the health carrier's
					 requirements for medical necessity, appropriateness, health care 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 the
					 requested benefit;
(ii)  the denial, reduction, or termination of, or failure
					 to provide or make payment in whole or in part for, a benefit based on a
					 determination by a health carrier or its designee utilization review entity of
					 a covered person's eligibility to participate in the health carrier's health
					 benefit plan;
(iii)  any review determination that denies, reduces, or
					 terminates or fails to provide or make payment, in whole or in part, for a
					 benefit;
(iv)  a rescission of coverage determination as defined in
					 § 38.2-3438 of the Code of Virginia; or
(v)  any decision to deny individual coverage in an initial
					 eligibility determination.
"Adverse determination" in the context of external review
					 means a determination by a health carrier or its designee utilization review
					 entity 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 or is determined to be experimental or investigational and the
					 requested service or payment for the service is therefore denied, reduced, or
					 terminated.
"Authorized representative" means
(i)  a person to whom a covered person has given express
					 written consent to represent the covered person;
(ii)  a person authorized by law to provide substituted
					 consent for a covered person;
(iii)  a family member of a covered person or the covered
					 person's treating health care professional when the covered person is unable to
					 provide consent;
(iv)  a health care professional when the covered person's
					 health benefit plan requires that a request for a benefit under the plan be
					 initiated by the health care professional; or
(v)  in the case of an urgent care internal appeal, a health
					 care professional with knowledge of the covered person's medical
					 condition.
"Clinical peer reviewer" means a practicing health care
					 professional who holds a nonrestricted license in a state, district, or
					 territory of the United States and in the same or similar specialty as
					 typically manages the medical condition, procedure, or treatment under
					 appeal.
"Commission" means the State Corporation Commission.
"Concurrent review" means utilization review conducted
					 during a patient's stay or course of treatment in a facility, the office of a
					 health care professional, or other inpatient or outpatient health care
					 setting.
"Covered person" means a policyholder, subscriber,
					 enrollee, or other individual participating in a health benefit plan. For
					 purposes of this chapter with respect to the administration of appeals,
					 references to a covered person include a covered person's authorized
					 representative, if any.
"Emergency services" means those health care services that
					 are rendered after the sudden onset of a medical condition that manifests
					 itself by symptoms of sufficient severity, including severe pain, that the
					 absence of immediate medical attention could reasonably be expected by a
					 prudent layperson who possesses an average knowledge of health and medicine to
					 result in (i) serious jeopardy to the mental or physical health of the
					 individual, (ii) danger of serious impairment of the individual's bodily
					 functions, (iii) serious dysfunction of any of the individual's bodily organs,
					 or (iv) in the case of a pregnant woman, serious jeopardy to the health of the
					 fetus.
"Exception request" means a process that allows a covered
					 person, authorized representative, or prescribing physician (or other
					 prescriber, as appropriate) to request and gain access to clinically
					 appropriate drugs not otherwise covered by a health benefit plan in the
					 individual and small group market because of formulary restrictions .
"Final adverse determination" means an adverse
					 determination involving a covered benefit that has been upheld by a health
					 carrier, or its designee utilization review entity, at the completion of the
					 health carrier's internal appeal process.
"Group health plan" means an employee welfare benefit plan
					 (as defined in the Employee Retirement Income Security Act of 1974 (
					 29 USC §
											1002 (1)), to the extent that the plan
					 provides medical care and including items and services paid for as medical care
					 to employees or their dependents (as defined under the terms of the plan)
					 directly or through insurance, reimbursement, or otherwise.
"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. "Health benefit plan" does not include accident only, credit, or
					 disability insurance; coverage of Medicare services or federal employee health
					 plans pursuant to contracts with the United States government; Medicare
					 supplement or long-term care insurance; Medicaid coverage; dental only or
					 vision only insurance; specified disease insurance; hospital indemnity
					 coverage; limited benefit health coverage; coverage issued as a supplement to
					 liability insurance; insurance arising out of a workers' compensation or
					 similar law; automobile medical payment insurance; medical expense and loss of
					 income benefits; or insurance under which benefits are payable with or without
					 regard to fault and that is statutorily required to be contained in any
					 liability insurance policy or equivalent self-insurance.
"Health care professional" means a physician or other
					 health care practitioner licensed, accredited, or certified to perform
					 specified health care services consistent with the laws of the
					 Commonwealth.
"Health carrier" means an entity, subject to the insurance
					 laws and regulations of the Commonwealth or subject to the jurisdiction of the
					 commission, that contracts or offers to contract to provide, deliver, arrange
					 for, pay for, or reimburse any of the costs of health care services, including
					 an accident and sickness insurance company, a health maintenance organization,
					 a nonprofit hospital and health service corporation, or a nonstock corporation
					 offering or administering a health services plan, a hospital services plan, or
					 a medical or surgical services plan, or any other entity providing a plan of
					 health insurance, health benefits, or health care services except as excluded
					 under § 38.2-3557 of the Code of Virginia.
"Independent review organization" means an entity that
					 conducts independent external reviews of adverse determinations and final
					 adverse determinations, as well as alleged violations of
					 14VAC5-216-30 through
					 14VAC5-216-70 pertaining to
					 internal appeal.
"PPACA" means the Patient Protection and Affordable Care
					 Act ( P.L.
					 111-148 ), as amended by the Health Care and
					 Education Reconciliation Act of 2010 (
					 P.L.
					 111-152 ).
"Pre-service claim" means a claim for a benefit under a
					 health benefit plan that requires approval of the benefit in whole or in part,
					 in advance of obtaining the service or treatment.
"Post-service claim" means a claim for a benefit under a
					 health benefit plan that is not a pre-service claim, or the service or
					 treatment has been provided to the covered person.
"Self-insured plan" means an "employee welfare benefit
					 plan" that has the meaning set forth in the Employee Retirement Income Security
					 Act of 1974, 29 USC §
											1002 (1).
"Urgent care appeal" means an appeal for medical care or
					 treatment with respect to which the application of the time periods for making
					 non-urgent care determinations (i) could seriously jeopardize the life or
					 health of the covered person or the ability of the covered person to regain
					 maximum function; or (ii) in the opinion of the treating health care
					 professional with knowledge of the covered person's medical condition, would
					 subject the covered person to severe pain that cannot be adequately managed
					 without the care or treatment that is the subject of the appeal. An urgent care
					 appeal shall not be available for any post-service claim or retrospective
					 adverse benefit determination.
"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.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.