Terms Used In Hawaii Revised Statutes > Chapter 432E > Part II - General Policies

• 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
• 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
• 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
• 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
• 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
• 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 necessity: means a health intervention that meets the criteria enumerated in section 432E-1. See Hawaii Revised Statutes 432E-1
• 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
• provider: means a health care professional. See Hawaii Revised Statutes 432E-1