Ga. Comp. R. & Regs. R. 120-2-58-.02 - Definitions
(1) "Active
Practice" means activities including, but not limited to, the review of medical
records and charts, participation in utilization review and medical management,
evaluating medical necessity, monitoring patient therapy, graduate medical
education, or maintenance of board certification.
(2) "Adverse Determination" means a
determination based on medical necessity made by a private review agent or
utilization review entity not to grant authorization to a hospital, surgical or
other facility admission, extension of a hospital stay or other health care
service or procedure based on medical necessity or appropriateness.
(3) "Appeal" means a formal request, either
orally, or in writing or by electronic transmission, to a private review agent
to reconsider a determination not to certify an admission, extension of stay,
or other health care service or procedure.
(4) "Authorization" means a determination by
a private review agent or utilization review entity that a healthcare service
has been reviewed and, based on the information provided, satisfies the
utilization review entity's requirements for medical necessity.
(5) "Claim Administrator" means any entity
that reviews and determines whether to pay claims to covered persons on behalf
of the healthcare plan. Such payment determinations are made on the basis of
contract provisions including medical necessity and other factors. Claim
administrators may be insurers or their designated review organization,
self-insured employers, management firms, third-party administrators, or other
private contractors.
(6) "Clinical
Criteria" means the written policies, decisions, rules, medical protocols, or
guidelines used by a private review agent or utilization review entity to
determine medical necessity.
(7)
"Clinical Peer" means a healthcare provider who is licensed without restriction
or otherwise legally authorized and currently in active practice in the same or
similar specialty as that of the treating provider, and who typically manages
the medical condition or disease at issue and has knowledge of and experience
providing the healthcare service or treatment under review.
(8) "Complaint" is a communication either
orally, in writing or by electronic transmission concerning matters related to
utilization review including, but not limited to, health care services,
denials, accessibility, and confidentiality.
(9) "Concurrent Review" means utilization
review conducted during a patient's hospital stay or course of
treatment.
(10) "Covered Person"
means an individual, including, but not limited to, any subscriber, enrollee,
member, beneficiary, participant, or his or her dependent, eligible to receive
healthcare benefits by a health insurer pursuant to a healthcare plan or other
health insurance coverage.
(11)
Emergency healthcare services means healthcare services rendered after the
recent onset of a medical or traumatic condition, sickness, or injury
exhibiting acute symptoms of sufficient severity, including, but not limited
to, severe pain, that would lead a prudent layperson possessing an average
knowledge of medicine and health to believe that his or her condition,
sickness, or injury is of such a nature that failure to obtain immediate
medical care could result in:
(A) Placing the
patient's health in serious jeopardy;
(B) Serious impairment to bodily functions;
or
(C) Serious dysfunction of any
bodily organ or part.
(12) "Facility" means a hospital, ambulatory
surgical center, birthing center, diagnostic and treatment center, hospice, or
similar institution. Such term shall not mean a healthcare provider's
office.
(13) "Health insurer" or
"insurer" means an accident and sickness insurer, care management organization,
healthcare corporation, health maintenance organization provider sponsored
healthcare corporation, or any similar entity regulated by the Commissioner.
(14) "Healthcare plan" means any
hospital or medical insurance policy or certificate, qualified higher
deductible health plan, stand-alone dental plan, health maintenance
organization or other managed care subscriber contract, the state health
benefit plan, or any plan entered into by a care management organization as
permitted by the Department of Community Health for the delivery of healthcare
services.
(15) "Healthcare service"
means healthcare procedures, treatments, or services provided by a facility
licensed in this state or provided within the scope of practice of a doctor of
medicine, a doctor of osteopathy, or another healthcare provider licensed in
this state. Such term includes but is not limited to the provision of
pharmaceutical products or services or durable medical equipment.
(16) "Medical necessity" or 'medically
necessary' means healthcare services that a prudent physician or other
healthcare provider would provide to a patient for the purpose of preventing,
diagnosing, or treating an illness, injury, or disease or its symptoms in a
manner that is:
(A) In accordance with
generally accepted standards of medical or other healthcare practice;
(B) Clinically appropriate in terms of type,
frequency, extent, site, and duration;
(C) Not primarily for the economic benefit of
the health insurer or for the convenience of the patient, treating physician,
or other healthcare provider; and
(D) Not primarily custodial care, unless
custodial care is a covered service or benefit under the covered person's
healthcare plan.
(17)
"Pharmacy benefits manager" means a person, business entity, or other entity
that performs pharmacy benefits management. Such term includes a person or
entity acting for a pharmacy benefits manager in a contractual or employment
relationship in the performance of pharmacy benefits management for a
healthcare plan. Such term shall not include services provided by pharmacies
operating under a hospital pharmacy license. Such term shall not include health
systems while providing pharmacy services for their patients, employees, or
beneficiaries, for indigent care, or for the provision of drugs for outpatient
procedures. Such term shall not include services provided by pharmacies
affiliated with a facility licensed under Code Section
31-44-4 or a licensed group model
health maintenance organization with an exclusive medical group contract and
which operates its own pharmacies which are licensed under Code Section
26-4-110.
(18) "Prior authorization" means any written
or oral determination made at any time by a claim administrator or an insurer,
or any agent thereof, that a covered person's receipt of healthcare services is
a covered benefit under the applicable plan and that any requirement of medical
necessity or other requirements imposed by such plan as prerequisites for
payment for such services have been satisfied. The term 'agent' as used in this
paragraph shall not include an agent or agency as defined in Code Section
33-23-1.
(19) "Private review agent" means any person
or entity which performs utilization review for:
(A) An employer with employees who are
treated by a health care healthcare provider in this state;
(B) An insurer; or
(C) A claim administrator.
(20) "Reconsideration" means a
request either orally, in writing or by electronic transmission to the private
review agent to reconsider an adverse determination.
(21) "Review Criteria" means the written
policies, decisions, rules, medical protocols or guidelines used by the private
review agent to determine medical necessity or appropriateness.
(22) "Urgent healthcare service" means a
healthcare service with respect to which the application of the time periods
for making a nonexpedited prior authorization, which, in the opinion of a
physician or other healthcare provider with knowledge of the covered person's
medical condition:
(A) Could seriously
jeopardize the life or health of the covered person or the ability of such
person to regain maximum function; or
(B) Could subject the covered person to
severe pain that cannot be adequately managed without the care or treatment
that is the subject of the utilization review. Such term shall include services
provided for the treatment of substance use disorders which otherwise qualify
as an urgent healthcare service.
(23) "Utilization review entity" means an
insurer or other entity that performs prior authorization for one or more of
the following entities:
(A) An insurer that
writes health insurance policies;
(B) A preferred provider organization or
health maintenance organization; or
(C) Any other individual or entity that
provides, offers to provide, or administers hospital, outpatient, medical,
behavioral health, prescription drug, or other health benefits to a person
treated by a healthcare provider in this state under a health insurance policy,
plan, or contract.
(24)
"Utilization Review Determination" means a recommendation by a private review
agent regarding medical necessity or appropriateness of the health care
services given or proposed to be given to a patient.
Notes
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