Utah Admin. Code 590-261-3

Current through Bulletin 2024-24, December 15, 2024

Section R590-261-3 - Definitions

Terms used in this rule are defined in Section 31A-1-301 and 45 CFR 147.140. Additional terms are defined as follows:

(1)

(a) "Adverse benefit determination" means:

(i) based on the carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, the:

(A) denial of a benefit;

(B) reduction of a benefit;

(C) termination of a benefit; or

(D) failure to provide or make payment, in whole or part, for a benefit; or

(ii) rescission of coverage.

(b) "Adverse benefit determination" includes:

(i) denial, reduction, termination, or failure to provide or make payment that is based on a determination of an insured's eligibility to participate in a health benefit plan;

(ii) failure to provide or make payment, in whole or part, for a benefit resulting from the application of a utilization review; and

(iii) failure to cover an item or service for which benefits are otherwise provided because it is determined to be:

(A) experimental;

(B) investigational; or

(C) not medically necessary or appropriate.

(2) "Authorized representative" means:

(a) a person to whom an insured has given express written consent for representation in an external review;

(b) a person authorized by law to provide substituted consent for an insured; or

(c) when the insured is unable to provide consent:

(i) a family member of the insured; or

(ii) the insured's treating health care provider.

(3) "Carrier" means a person that provides health insurance in this state including:

(a) an insurance company;

(b) a prepaid hospital or medical care plan;

(c) a health maintenance organization;

(d) a multiple employer welfare arrangement; and

(e) any other person providing a health insurance plan under Title 31A, Insurance Code.

(4) "Claimant" means the insured or the insured's authorized representative.

(5) "Clinical reviewer" means a physician or other appropriate health care provider who:

(a) is an expert in the treatment of the medical condition that is the subject of the review;

(b) is knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition;

(c) holds an appropriate license or certification; and

(d) has no history of disciplinary actions or sanctions. (6) "Final adverse benefit determination" means an adverse benefit determination that has been upheld by a carrier at the completion of the carrier's internal review process.

(7) "Independent review" means a process that:

(a) is a voluntary option for the resolution of a final adverse benefit determination;

(b) is conducted at the discretion of the claimant;

(c) is conducted by an independent review organization designated by the commissioner;

(d) renders an independent and impartial decision on a final adverse benefit determination; and

(e) may not require the claimant to pay a fee for requesting the independent review.

(8)

(a) "Rescission" means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect.

(b) "Rescission" does not include a cancellation or discontinuance of coverage under a health benefit plan if the cancellation or discontinuance of coverage:

(i) has only a prospective effect; or

(ii) is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions toward the cost of coverage.

Utah Admin. Code R590-261-3

Amended by Utah State Bulletin Number 2023-10, effective 5/9/2023