Terms Used In Hawaii Revised Statutes > Chapter 432E - Patients' Bill of Rights and Responsibilities Act

• Adverse action: means an adverse determination or a final adverse determination. See Hawaii Revised Statutes 432E-1
• Adverse determination: means a determination by a health carrier or its designated 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. See Hawaii Revised Statutes 432E-1
• Ambulatory review: means a utilization review of health care services performed or provided in an outpatient setting. See Hawaii Revised Statutes 432E-1
• Appeal: means a request from an enrollee to change a previous decision made by the health carrier. See Hawaii Revised Statutes 432E-1
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appointed representative: means a person who is expressly permitted by the enrollee or who has the power under Hawaii law to make health care decisions on behalf of the enrollee, including:

  (1) A person to whom an enrollee has given express written consent to represent the enrollee in an external review;

  (2) A person authorized by law to provide substituted consent for an enrollee;

  (3) A family member of the enrollee or the enrollee's treating health care professional, only when the enrollee is unable to provide consent;

  (4) A court-appointed legal guardian;

  (5) A person who has a durable power of attorney for health care; or

  (6) A person who is designated in a written advance directive;

  provided that an appointed representative shall include an "authorized representative" as used in the federal Patient Protection and Affordable Care Act. See Hawaii Revised Statutes 432E-1

• benefits: means those health care services to which an enrollee is entitled under the terms of a health benefit plan. See Hawaii Revised Statutes 432E-1
• 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 the trials in paragraphs (1) and (2) are not available, case-series; or

  (4) If the sources of information in paragraphs (1), (2), and (3) are not available, expert opinion. See Hawaii Revised Statutes 432E-1

• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Hawaii Revised Statutes 432E-1
• Case-series: means an evaluation of patients with a particular outcome, without the use of a control group. See Hawaii Revised Statutes 432E-1
• Certification: means a determination by a health carrier or its designated 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. See Hawaii Revised Statutes 432E-1
• 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. See Hawaii Revised Statutes 432E-1
• Commissioner: means the insurance commissioner. See Hawaii Revised Statutes 432E-1
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Complaint: means an expression of dissatisfaction, either oral or written. See Hawaii Revised Statutes 432E-1
• Concurrent review: means a utilization review conducted during a patient's hospital stay or course of treatment. See Hawaii Revised Statutes 432E-1
• Contract: A legal written agreement that becomes binding when signed.
• Conviction: A judgement of guilt against a criminal defendant.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that an enrollee receives following discharge from a facility. See Hawaii Revised Statutes 432E-1
• 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. See Hawaii Revised Statutes 432E-1
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Emergency services: means services provided to an enrollee when the enrollee has symptoms of sufficient severity, including severe pain, such that a layperson could reasonably expect, in the absence of medical treatment, to result in placing the enrollee's health or condition in serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, or death. See Hawaii Revised Statutes 432E-1
• Enrollee: means a person who enters into a contractual relationship under or who is provided with health care services or benefits through a health benefit plan. See Hawaii Revised Statutes 432E-1
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Expert opinion: means a belief or interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. See Hawaii Revised Statutes 432E-1
• External review: means a review of an adverse determination (including a final adverse determination) conducted by an independent review organization pursuant to this chapter. See Hawaii Revised Statutes 432E-1
• 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. See Hawaii Revised Statutes 432E-1
• Fiduciary: A trustee, executor, or administrator.
• Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier or its designated utilization review organization at the completion of the health carrier's internal grievance process procedures, or an adverse determination with respect to which the internal appeals process is deemed to have been exhausted under section 432E-33(b). See Hawaii Revised Statutes 432E-1
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health benefit plan: means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay or reimburse any of the costs of health care services. See Hawaii Revised Statutes 432E-1
• Health care professional: means an individual licensed, accredited, or certified to provide or perform specified health care services in the ordinary course of business or practice of a profession consistent with state law. See Hawaii Revised Statutes 432E-1
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Hawaii Revised Statutes 432E-1
• Health carrier: means an entity subject to the insurance laws and rules 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 mutual benefit society, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health care services. See Hawaii Revised Statutes 432E-1
• Health maintenance organization: means a health maintenance organization as defined in § 432D-1. See Hawaii Revised Statutes 432E-1
• Independent review organization: means an independent entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Hawaii Revised Statutes 432E-1
• Internal review: means the review under § 432E-5 of an enrollee's complaint by a health carrier. See Hawaii Revised Statutes 432E-1
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Managed care plan: means any plan, policy, contract, certificate, or agreement, regardless of form, offered or administered by any person or entity, including but not limited to an insurer governed by chapter 431, a mutual benefit society governed by chapter 432, a health maintenance organization governed by chapter 432D, a preferred provider organization, a point of service organization, a health insurance issuer, a fiscal intermediary, a payor, a prepaid health care plan, and any other mixed model, that provides for the financing or delivery of health care services or benefits to enrollees through:

  (1) Arrangements with selected providers or provider networks to furnish health care services or benefits; and

  (2) Financial incentives for enrollees to use participating providers and procedures provided by a plan;

  provided that for the purposes of this chapter, an employee benefit plan shall not be deemed a managed care plan with respect to any provision of this chapter or to any requirement or rule imposed or permitted by this chapter that is superseded or preempted by federal law. See Hawaii Revised Statutes 432E-1

• Medical director: means the person who is authorized under a health carrier and who makes decisions for the health carrier denying or allowing payment for medical treatments, services, or supplies based on medical necessity or other appropriate medical or health plan benefit standards. See Hawaii Revised Statutes 432E-1
• Medical necessity: means a health intervention that meets the criteria enumerated in section 432E-1. See Hawaii Revised Statutes 432E-1
• 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 National Library of Medicine for indexing in Index Medicus and Elsevier Science Ltd. See Hawaii Revised Statutes 432E-1

• month: means a calendar month; and the word "year" a calendar year. See Hawaii Revised Statutes 1-20
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Participating provider: means a licensed or certified provider of health care services or benefits, including mental health services and health care supplies, who has entered into an agreement with a health carrier to provide those services or supplies to enrollees. See Hawaii Revised Statutes 432E-1
• Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. ^{Source: OCC}
• Prospective review: means utilization review conducted prior to an admission or a course of treatment. See Hawaii Revised Statutes 432E-1
• Protected health information: means health information as defined in the federal Health Insurance Portability and Accountability Act and related federal rules. See Hawaii Revised Statutes 432E-1
• provider: means a health care professional. See Hawaii Revised Statutes 432E-1
• Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. ^{Source: FDIC}
• Retrospective review: means a review of medical necessity conducted after services that 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. See Hawaii Revised Statutes 432E-1
• Reviewer: means an independent reviewer with clinical expertise either employed by or contracted by an independent review organization to perform external reviews. See Hawaii Revised Statutes 432E-1
• 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. See Hawaii Revised Statutes 432E-1
• Specifically excluded: means that the coverage provisions of the health care plan, when read together, clearly and specifically exclude coverage for a health care service. See Hawaii Revised Statutes 432E-1
• telecommunications: means the offering of transmission between or among points specified by a user, of information of the user's choosing, including voice, data, image, graphics, and video without change in the form or content of the information, as sent and received, by means of electromagnetic transmission, or other similarly capable means of transmission, with or without benefit of any closed transmission medium, and does not include cable service as defined in § 440G-3. See Hawaii Revised Statutes 269-1
• Testify: Answer questions in court.
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• 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. See Hawaii Revised Statutes 432E-1
• Utilization review organization: means an entity that conducts utilization review other than a health carrier performing a review for its own health benefit plans. See Hawaii Revised Statutes 432E-1