As used in this part, unless the context otherwise requires:
(1) “Adverse determination” has the same meaning as defined in § 56-61-102;
(2) “Clinical criteria” means the written policies, screening procedures, decision rules, decision abstracts, clinical protocols, practice guidelines, and medical protocols used by the utilization review agent to determine the necessity and appropriateness of health care services;
(3) “Commissioner” means the commissioner of commerce and insurance;
(4) “Enrollee” means an individual who has contracted for or who participates in coverage under an insurance policy, a health maintenance organization contract, a health service corporation contract, an employee welfare benefit plan, a hospital or medical services plan, or any other benefit program providing payment, reimbursement, or indemnification for health care costs for the individual or the individual’s eligible dependents;
(5) “Final adverse determination” has the same meaning as defined in § 56-61-102;
(6) “Health care service” means health care procedures, treatments, or services provided by a facility licensed in this state or provided by a doctor of medicine, a doctor of osteopathy, or a health care professional licensed in this state;
(7) “Healthcare facility” means an institution, place, or building providing healthcare services that is required to be licensed under title 68, chapter 11, or title 33;
(8) “Medical necessity” has the same meaning as defined in § 56-61-102;
(9) “Preauthorization” means the process by which the utilization review agent determines the medical necessity of otherwise covered health care services prior to the rendering of such health care services including, but not limited to, preadmission review, pretreatment review, utilization, and case management;
(10) “Provider of record” means the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for the care, treatment, and services rendered to an individual;
(11)
(A) “Utilization review” means a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within this state;
(B) “Utilization review” does not include elective requests for clarification of coverage; and
(12) “Utilization review agent” means any person or entity, including the state, performing utilization review, except:
(A) An agency of the federal government;
(B) An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government;
(C) A hospital’s internal quality assurance program;
(D) An employee of a utilization review agent; or
(E) Health maintenance organizations licensed and regulated by the commissioner, but only to the extent of providing utilization review to their own members.
