Terms Used In Louisiana Revised Statutes > Title 22 > Chapter 18 > Part II - Internal Claims and Appeals Process Part Iii. Health Insurance Issuer External Review Act

• Adverse determination: means any of the following:

              (a) A determination by a health insurance issuer or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer'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 benefit. See Louisiana Revised Statutes 22:2392

• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Authorized representative: means any of the following:

              (a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392

• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Louisiana Revised Statutes 22:2392
• Board: means the Louisiana State Board of Medical Examiners. See Louisiana Revised Statutes 37:611
• Business day: means a day of normal business operation other than federally recognized holidays. See Louisiana Revised Statutes 22:2392
• Chambers: A judge's office.
• Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
• Clinical peer: means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review. See Louisiana Revised Statutes 22:2392
• Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health insurance issuer to determine the medical necessity and appropriateness of health care services including those used in the determination of an item or health care service as experimental. See Louisiana Revised Statutes 22:2392
• Combination of vehicles: means every group of two or more vehicles howsoever joined together which are drawn or propelled by a single motor vehicle. See Louisiana Revised Statutes 32:1
• Commissioner: means the secretary of the Department of Public Safety and Corrections. See Louisiana Revised Statutes 32:1
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
• Conviction: A judgement of guilt against a criminal defendant.
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Department: means the Department of Transportation and Development. See Louisiana Revised Statutes 32:1
• 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 Louisiana Revised Statutes 22:2392
• Driver: means every person who drives or is in actual physical control of a vehicle. See Louisiana Revised Statutes 32:1
• Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Louisiana Revised Statutes 22:2392
• entity: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Louisiana Revised Statutes 22:2392
• Evidence-based standard: means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients. See Louisiana Revised Statutes 22:2392
• 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, rehabilitation and other therapeutic health settings, and inpatient hospice facilities. See Louisiana Revised Statutes 22:2392
• Final adverse determination: means an adverse determination, including medical judgment, involving a covered benefit that has been upheld by a health insurance issuer, or its designee utilization review organization, at the completion of the health insurance issuer's internal claims and appeals process procedures provided pursuant to La. See Louisiana Revised Statutes 22:2392
• Firm: shall mean any domestic or foreign firm, partnership, association, cooperative, venture, corporation, limited liability company, limited liability partnership, or any other entity. See Louisiana Revised Statutes 37:682
• Fraud: Intentional deception resulting in injury to another.
• Grievance: means , in a health insurance issuer's internal claims and appeals process, a written complaint or oral complaint, if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding any of the following:

              (a) Availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review. See Louisiana Revised Statutes 22:2392

• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
• Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:2392
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:2392
• Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to any of the following:

              (a) The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family. See Louisiana Revised Statutes 22:2392

• Health insurance issuer: means an entity subject to the insurance laws and regulations 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 through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
• Immediately: means as expeditiously as the medical situation of the covered person requires but in no event longer than one day for expedited reviews or one business day for standard reviews. See Louisiana Revised Statutes 22:2392
• Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
• Injunction: An order of the court prohibiting (or compelling) the performance of a specific act to prevent irreparable damage or injury.
• Medical or scientific evidence: means evidence found in the following sources:

              (a) 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. See Louisiana Revised Statutes 22:2392

• Motor vehicle: means every vehicle which is self-propelled, and every vehicle which is propelled by electric power obtained from overhead trolley wires, but not operated upon rails, but excluding a motorized bicycle and an electric-assisted bicycle. See Louisiana Revised Statutes 32:1
• Oversight: Committee review of the activities of a Federal agency or program.
• Owner: means a person who holds a legal title to a vehicle or in the event a vehicle is the subject of an agreement for the conditional sale, lease, or transfer of possession thereof with the right of purchase upon the performance of the conditions stated in the agreement, with the right of immediate possession in the vendee, lessee, possessor, or in the event such similar transaction is had by means of mortgage and the mortgagor of a vehicle is entitled to possession, then the conditional vendee, lessee, possessor, or mortgagor shall be deemed the owner for the purposes of this Chapter. See Louisiana Revised Statutes 32:1
• Person: shall mean any individual or firm. See Louisiana Revised Statutes 37:682
• person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
• Police officer: means every officer authorized to direct or regulate traffic or to make arrests for violations of traffic regulations. See Louisiana Revised Statutes 32:1
• professional engineer: shall mean an individual who, by reason of his special knowledge and ability to apply the mathematical, physical, and engineering sciences and the principles and methods of engineering analysis and design, acquired by an engineering education and engineering experience, is qualified to practice engineering, as evidenced by his licensure as such by the board. See Louisiana Revised Statutes 37:682
• professional land surveyor: shall mean an individual who is qualified to practice land surveying, as evidenced by his licensure as such by the board. See Louisiana Revised Statutes 37:682
• Protected health information: means either of the following:

              (a) Health information that identifies an individual who is the subject of the information. See Louisiana Revised Statutes 22:2392

• provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
• Retrospective review: means a utilization review conducted after services 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 Louisiana Revised Statutes 22:2392
• Secretary: means the secretary of the Department of Transportation and Development or his delegated or authorized representative. See Louisiana Revised Statutes 32:1
• Special permit: means a written authorization to move or operate on a highway a vehicle or combination of vehicles with indivisible load of size and/or weight exceeding the limits prescribed for vehicles in regular operation. See Louisiana Revised Statutes 32:1
• Stop: means , when required, the complete cessation from movement. See Louisiana Revised Statutes 32:1
• stopping: means , when prohibited, any halting, even momentarily of a vehicle, whether occupied or not, except when necessary to avoid conflict with other traffic or in compliance with the directions of a police officer, weights and standards police officer, or traffic control sign or signal. See Louisiana Revised Statutes 32:1
• Summons: Another word for subpoena used by the criminal justice system.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Traffic: means pedestrians, ridden or herded animals, vehicles, and other conveyances either singly or together while using any highway for purposes of travel. See Louisiana Revised Statutes 32:1
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• 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 or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
• Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to La. See Louisiana Revised Statutes 22:2392
• Vehicle: means every device by which persons or things may be transported upon a public highway or bridge, except devices moved by human power or used exclusively upon stationary rails or tracks. See Louisiana Revised Statutes 32:1
• Venue: The geographical location in which a case is tried.