Terms Used In Louisiana Revised Statutes > Title 33 > Chapter 1 > Part I > Subpart A - Municipal Incorporation

• 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.
• 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.
• 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

• 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
• 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
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
• 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.
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. 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
• 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
• 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.
• 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
• 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 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
• 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.
• person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
• 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
• Summons: Another word for subpoena used by the criminal justice system.
• 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