Terms Used In Louisiana Revised Statutes > Title 22 > Chapter 20 - Louisiana Health Insurance Innovation and Stabilization Program

• Accumulated contributions: means the sum of all amounts paid by a member, excluding interest paid on the repayment of a refund, and credited to his individual account in the employee's savings account, together with regular interest credited prior to July 1969. See Louisiana Revised Statutes 11:403
• 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.
• Agency: means any governmental body employing persons and includes departments, agencies, boards, commissions, and courts. See Louisiana Revised Statutes 11:403
• Ambulatory review: means utilization review of health care services performed or provided in an outpatient setting. See Louisiana Revised Statutes 22:2392
• 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

• Axle: means the common axis of rotation of one or more wheels whether power-driven or freely rotating, and whether in one or more segments, and regardless of the number of wheels carried thereon. See Louisiana Revised Statutes 32:1
• 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
• Best evidence: means evidence based on any of the following:

              (a) Randomized clinical trials. See Louisiana Revised Statutes 22:2392

• Board: means the Louisiana State Board of Medical Examiners. See Louisiana Revised Statutes 37:611
• Board: shall mean the Louisiana Professional Engineering and Land Surveying Board, provided for by this Chapter. See Louisiana Revised Statutes 37:682
• Business day: means a day of normal business operation other than federally recognized holidays. See Louisiana Revised Statutes 22:2392
• Candidate: means a person who seeks nomination or election to public office, except the office of president or vice president of the United States, presidential elector, delegate to a political party convention, United States senator, United States congressman, or political party office. See Louisiana Revised Statutes 18:1483
• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Louisiana Revised Statutes 22:2392
• Case-series: means an evaluation of a series of patients with a particular outcome, without the use of a control group. See Louisiana Revised Statutes 22:2392
• Chambers: A judge's office.
• 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
• committee: means two or more persons, other than a husband and wife, and any legal entity organized for the primary purpose of supporting or opposing one or more candidates, propositions, recalls of a public officer, or political parties, which accepts contributions in the name of the committee, or makes expenditures from committee funds or in the name of the committee, or makes a transfer of funds to or receives a transfer of funds from another committee, or receives or makes loans in an aggregate amount in excess of five hundred dollars within any calendar year. See Louisiana Revised Statutes 18:1483
• Concurrent review: means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or other inpatient or outpatient health care setting. See Louisiana Revised Statutes 22:2392
• Contract: A legal written agreement that becomes binding when signed.
• Contribution: except as otherwise provided in this Chapter, means a gift, conveyance, payment, or deposit of money or anything of value, or the forgiveness of a loan or of a debt, made for the purpose of supporting, opposing, or otherwise influencing the nomination or election of a person to public office, for the purpose of supporting or opposing a proposition or question submitted to the voters, or for the purpose of supporting or opposing the recall of a public officer, whether made before or after the election. See Louisiana Revised Statutes 18:1483
• 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
• Creditable service: means prior service plus membership service for which credit is allowable as provided in this Chapter. See Louisiana Revised Statutes 11:403
• Department: means the Department of Environmental Quality. See Louisiana Revised Statutes 30:2004
• Department: means the Department of Transportation and Development. See Louisiana Revised Statutes 32:1
• Devise: To gift property by will.
• Discharge: means discharge as defined in La. See Louisiana Revised Statutes 30:2272
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility. See Louisiana Revised Statutes 22:2392
• 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
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Disposal: means disposal as defined in La. See Louisiana Revised Statutes 30:2272
• Driver: means every person who drives or is in actual physical control of a vehicle. See Louisiana Revised Statutes 32:1
• Earned compensation: means the base pay earned by an employee for a given pay period as reported to the system on a monthly basis by the agency which shall include the cash value of any emolument of office in the form of paid compensation in lieu of salary which is subject to federal and state payroll taxes and includes the full amount earned by an employee, overtime, and per diem earned by an employee of the House of Representatives, the Senate, or an agency of the legislature, and expense allowances and per diem paid to members of the legislature, the clerk, or sergeant at arms of the House of Representatives and president and secretary or sergeant at arms of the Senate. See Louisiana Revised Statutes 11:403
• Election: means any primary, general, or special election held, pursuant to the laws of this state or a parish or municipal charter or ordinance or a court order, to choose a public officer or nominee. See Louisiana Revised Statutes 18:1483
• Emergency medical condition: means a medical condition manifesting itself by symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy. See Louisiana Revised Statutes 22:2392
• 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
• Employer: means the state of Louisiana or any of its boards, commissions, departments, agencies, and courts which are contributing members of the Louisiana State Employees' Retirement System. See Louisiana Revised Statutes 11:403
• 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
• Escrow: Money given to a third party to be held for payment until certain conditions are met.
• 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
• Expert opinion: means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. 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
• Fiduciary: A trustee, executor, or administrator.
• 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
• Fraud: Intentional deception resulting in injury to another.
• Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
• 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

• Gross weight: means the weight of a vehicle and/or combination of vehicles without load on all axles including the steering axle plus the weight of any load thereon. See Louisiana Revised Statutes 32:1
• Hazardous substance: means any gaseous, liquid, or solid material which because of its quantity, concentration, or physical, chemical, or biological composition when released into the environment poses a substantial present or potential hazard to human health, the environment, or property, and which material is identified or designated as being hazardous by rules and regulations adopted and promulgated by the secretaries of the Department of Environmental Quality or of the Department of Public Safety and Corrections, regardless of whether it is intended for use, reuse, or is to be discarded. See Louisiana Revised Statutes 30:2272
• Hazardous waste: means hazardous waste as defined in La. See Louisiana Revised Statutes 30:2272
• 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
• Highway: means the entire width between the boundary lines of every way or place of whatever nature publicly maintained and open to the use of the public for the purpose of vehicular travel, including bridges, causeways, tunnels and ferries; synonymous with the word "street". See Louisiana Revised Statutes 32:1
• 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.
• Interstate highway: means a fully controlled access highway which is a part of the National System of Interstate and Defense Highways. See Louisiana Revised Statutes 32:1
• Joint committee: Committees including membership from both houses of teh legislature. Joint committees are usually established with narrow jurisdictions and normally lack authority to report legislation.
• Jurisprudence: The study of law and the structure of the legal system.
• Law clerk: Assist judges with research and drafting of opinions.
• Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). ^{Source: OCC}
• Lien: A claim against real or personal property in satisfaction of a debt.
• Load: means a weight or quantity of anything resting upon something else regarded as its support. See Louisiana Revised Statutes 32:1
• 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

• Member: means any person included in the membership of the system. See Louisiana Revised Statutes 11:403
• Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
• 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
• Municipality: means an incorporated village, town, or city created under the authority of the constitution or laws of this state. See Louisiana Revised Statutes 32:1
• Operator: means every person, other than a chauffeur, who drives or is in actual physical control of a motor vehicle upon a highway or who is exercising control over or steering a vehicle being towed by a motor vehicle. 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
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Person: means any individual, municipality, public or private corporation, partnership, firm, the United States Government, and any agent or subdivision thereof or any other juridical person, which shall include, but not be limited to, trusts, joint stock companies, associations, the state of Louisiana, political subdivisions of the state of Louisiana, commissions, and interstate bodies. See Louisiana Revised Statutes 30:2004
• Person: means any individual, partnership, limited liability company or corporation, association, labor union, political committee, corporation, or other legal entity, including their subsidiaries. See Louisiana Revised Statutes 18:1483
• 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
• Position: means any office or any employment in the state service. See Louisiana Revised Statutes 11:403
• Prospective review: means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health insurance issuer's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. See Louisiana Revised Statutes 22:2392
• 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
• Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
• Quorum: The number of legislators that must be present to do business.
• Refund: means the withdrawal of all accumulated contributions at least thirty days after termination from the state service, or with respect to members having the option of belonging to the system, withdrawal of all accumulated contributions at least thirty days after receipt by the system of written notice of withdrawal. See Louisiana Revised Statutes 11:403
• Remand: When an appellate court sends a case back to a lower court for further proceedings.
• Reporter: Makes a record of court proceedings and prepares a transcript, and also publishes the court's opinions or decisions (in the courts of appeals).
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Rescission: means cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. See Louisiana Revised Statutes 22:2392
• Retirement: means termination of active service, with a retirement allowance granted under the provisions of this Chapter. See Louisiana Revised Statutes 11:403
• 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
• 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 or medical necessity and appropriateness of the initial proposed health care service. See Louisiana Revised Statutes 22:2392
• Secretary: means the secretary of the Department of Environmental Quality. See Louisiana Revised Statutes 30:2004
• 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
• State: means the state of Louisiana. See Louisiana Revised Statutes 11:403
• 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
• System: means the Louisiana State Employees' Retirement System. See Louisiana Revised Statutes 11:403
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Tort: A civil wrong or breach of a duty to another person, as outlined by law. A very common tort is negligent operation of a motor vehicle that results in property damage and personal injury in an automobile accident.
• 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
• Truck: means every motor propelled single vehicle for the conveyance of property or things for hauling purposes and having one front steering axle and one rear or load carrying axle. See Louisiana Revised Statutes 32:1
• Trustee: A person or institution holding and administering property in trust.
• Uniform Commercial Code: A set of statutes enacted by the various states to provide consistency among the states' commercial laws. It includes negotiable instruments, sales, stock transfers, trust and warehouse receipts, and bills of lading. ^{Source: OCC}
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Urgent care request: means :

              (a) A request for a health care service or course of treatment with respect to which the time periods for making a non-urgent care request determination either:

              (i) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function. See Louisiana Revised Statutes 22:2392

• 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.