Section 3 AAC 28.989 - DefinitionsIn 3 AAC 28.900 - 3 AAC 28.989, unless the context requires otherwise,
(1) "adverse determination" includes a rescission of coverage determination and means (A) a determination by a health care insurer or the health care insurer's designee utilization review organization that (i) based upon the information provided, a request for a benefit under the health care insurer's health care insurance policy upon application of a utilization review technique does not meet the health care insurer'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 riot provided or made, in whole or in part, for the benefit; or(ii) an admission, availability of care, continued stay, or other health care service or treatment that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health care insurer'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;(B) the denial, reduction, termination, or failure to provide or make payment, in whole or in part, for a benefit based on a determination by a health care insurer or the health care insurer's designee utilization review organization of a covered person's eligibility to participate in the health care insurer's health care insurance policy; or(C) a prospective review or retrospective review determination that denies, reduces, or terminates or fails to provide or make payment, in whole or in part, for a benefit;(2) "applicable non-English language" means a non-English language if 10 percent or more of the population residing in a borough equivalent is literate only in the same non-English language as determined in CLAS County Data, Edition Date: January 2016, issued by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, on January 27. 2016, and adopted by reference;(3) "authorized representative" means (A) a person to whom a covered person has given express written consent to represent the covered person for purposes of 3 AAC 28.900 - 3 AAC 28.982;(B) a person authorized by law to provide substituted consent for a covered person;(C) one of the following only if the covered person is unable to provide consent: (i) a family member of the covered person; or(ii) the covered person's treating health care professional;(D) a health care professional if the covered person's health care insurance policy requires that a request for a benefit under the plan be initiated by the health care professional; or(E) if the person is making an urgent care request, a health care professional with knowledge of the covered person's medical condition;(4) "best evidence" means evidence based on randomized clinical trials; if randomized clinical trials are not available, "best evidence" means evidence based on cohort studies or case-control studies; if randomized clinical trials, cohort studies, or case-control studies are not available, "best evidence" means evidence based on case-series studies; if none of these are available, "best evidence" means evidence based on expert opinion;(5) "borough equivalent" means (A) a unified municipality;(B) an organized borough; or(C) a census area used by the United States Secretary of Commerce in the last decennial census that is located in the unorganized borough of the state;(6) "case-control study" means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received;(7) "case-series study" means an evaluation of a series of patients with a particular outcome, without the use of a control group;(8) "certification" means a determination by a health care insurer or the health care insurer's designee utilization review organization that a request for a benefit under the health care insurer's health care insurance policy has been reviewed and, based on the information provided, satisfies the health care insurer's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness;(9) "clinical peer" means a physician or other health care professional who holds a non-restricted 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;(10) "clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health care insurer to determine the medical necessity and appropriateness of health care services;(11) "closed plan" means a managed care plan that requires a covered person to use participating providers under the terms of the managed care plan;(12) "cohort study" means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention;(13) "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;(14) "covered benefit" or "benefit" means a health care service to which a covered person is entitled under the terms of a health care insurance policy;(15) "covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health care insurance policy;(16) "denial code" means a health care insurer specific identifier indicating the reason why a claim is being denied;(17) "department" means the Department of Commerce, Community, and Economic Development;(18) "diagnosis code" means a universal code used by a health care provider to categorize a health condition, illness, injury, or disease;(19) "director" means the director of the division of insurance;(20) "disclose" means to release, transfer, or otherwise divulge protected health information to a person other than the individual who is the subject of the protected health information;(21) "division" means the division of insurance, Department of Commerce, Community, and Economic Development;(22) "emergency medical condition*' has the meaning given in AS 21.07.250;(23) "emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition;(24) "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;(25) "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;(26) "facility" (A) means an institution providing health care services or a health care setting;(B) includes 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;(27) "final adverse determination" means an(A) adverse determination that has been upheld by a health care insurer at the completion of the internal review process applicable under 3 AAC 28.936 or 3 AAC 28.938; or(B) adverse determination that, with respect to the internal review process, has been considered exhausted under 3 AAC 28.934(b);(28) "grievance" means a written complaint or, if the complaint involves an urgent care request, an oral complaint, submitted by or on behalf of a covered person regarding(A) the availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made under utilization review;(B) claims payment, handling, or reimbursement for health care services; or(C) matters pertaining to the contractual relationship between a covered person and a health care insurer;(29) "health care insurance policy" means a policy, contract, certificate, or agreement offered or issued by a health care insurer to provide, deliver, arrange for, pay for. or reimburse the costs Of health care services of treatments;(30) "health care professional" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with state law;(31) "health care provider" or "provider" means a health care professional or a facility;(32) "health care services" means services for the diagnosis, prevention treatment, cure, or relief of a health condition, illness, injury, or disease;(33) "health care insurer" has the meaning given in AS 21.07.250;(34) "health information" means data or information, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to 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;(B) the provision of health care services or treatments to an individual;(C) payment for the provision of health care services or treatments to an individual;(35) "independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations;(36) "managed care plan" (A) means a health care insurance policy that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, owned, under contract with, or employed by a health care insurer;(37) "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 (i) meet nationally recognized requirements for scientific manuscripts; and(ii) submit most of their published articles for review by experts who are not part of the editorial staff;(B) 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 National Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Exccrpta Medicus (EMBASE);(C) medical journals recognized by the United States Secretary of Health and Human Services under 42 U.S.C. 1395x(t)(2) (Social Security Act);(D) the following standard reference compendia: (i)American Hospital Formulary Service - Drug Information', (ii)Drug Facts and Comparisons;(iii) American Dental Association Accepted Dental Therapeutics; and(iv)United States Pharmacopoeia - Drug Information;(E) findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the following (i) Agency for Healthcare Research and Quality;(ii) National Institutes of Health;(iii) National Cancer Institute;(iv) National Academy of Sciences;(v) Centers for Medicare and Medicaid Services;(vi) United States Food and Drug Administration; and(vii) a national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services or treatments;(F) other medical or scientific evidence that is comparable to the sources listed in (A) - (E) of this paragraph;(38) "network" means the group of participating providers providing services to a managed care plan;(39) "open plan" means a managed care plan other than a closed plan that provides Incentives, including financial incentives, for a covered person to use participating providers under the terms of the managed care plan;(40) "participating provider" means a provider who, under contract with a health care insurer or with the health care insurer's contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health care insurer;(41) "person" (A) has the meaning given in AS 21.97.900;(B) includes a joint venture and a joint stock company;(42) "prospective review" means utilization review conducted before an admission or course of treatment;(43) "protected health information" means health information (A) that identifies an individual who is the subject of the information; or(B) with respect to which there is a reasonable basis to believe that the information could be used to identify an individual;(44) "randomized clinical trial" means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time;(45) "rescission" (A) means a cancellation or discontinuance of coverage under a health care insurance policy that has a retroactive effect;(B) does not include a cancellation or discontinuance of coverage under a health care insurance policy if (i) the cancellation or discontinuance of coverage has only a prospective effect; or(ii) the cancellation of discontinuance of coverage is effective retroactively to the extent the cancellation or discontinuance is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage;(46) "retrospective review" (A) means review of medical necessity conducted after services have been provided to a patient;(B) does not include the review of a claim that is limited to (i) veracity of documentation; or(47) "treatment code" means a universal code used by a health care provider to identify a service or supply provided to an insured under a health care insurance policy;(48) "urgent care request" means a request (A) for a health care service or course of treatment with respect to which the time period for making a non-urgent care request determination (i) could seriously jeopardize the life or health of the covered person to regain maximum function; or(ii) in the opinion of an attending health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request;(B) that an attending health care professional with knowledge of the covered person's medical condition determines is an urgent care request under (A) of this paragraph;(C) except under (B) of this paragraph, that an individual determines is an urgent care request if the individual is (i) acting on behalf of a health care insurer; and (ii) applying the judgment of a prudent layperson who has an average knowledge of health and medicine;(49) "utilization review" has the meaning given in AS 21.07.250;(50) "utilization review organization" means an entity that conducts utilization review, other than a health care insurer performing utilization review for the health care insurer's own benefit plans;(51) "working day" has the meaning given in AS 21.97.900. Eff. 3/15/2018,Register 225, April 2018CLAS County Data, Edition Date: January 2016, issued by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, on January 27, 2016, may be obtained from the Centers for Medicare and Medicaid Services website at https://www.ems.gov/CCIIO/Resources/Fact-Sheets-and-F A Qs/Downloads/CLASCounty- Data_Jan-2016-update-FINAL.pdf, the Alaska Division of Insurance website at https://www.commerce.alaska.gov/web/ins/, or by writing to the Alaska Division of Insurance, P.O. Box 110805, Juneau, AK 99801-0805, or by contracting the division at insurance@ alaska. gov.
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Authority:AS 21.06.090
AS 21.07.005