Terms Used In Hawaii Revised Statutes > Chapter 432E > Part IV - External Review of Health Insurance Determinations

• Adverse action: means an adverse determination or a final adverse determination. See Hawaii Revised Statutes 432E-1
• Adverse determination: means a determination by a health carrier or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier'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. See Hawaii Revised Statutes 432E-1
• 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.
• Appeal: means a request from an enrollee to change a previous decision made by the health carrier. See Hawaii Revised Statutes 432E-1
• Appointed representative: means a person who is expressly permitted by the enrollee or who has the power under Hawaii law to make health care decisions on behalf of the enrollee, including:

  (1) A person to whom an enrollee has given express written consent to represent the enrollee in an external review;

  (2) A person authorized by law to provide substituted consent for an enrollee;

  (3) A family member of the enrollee or the enrollee's treating health care professional, only when the enrollee is unable to provide consent;

  (4) A court-appointed legal guardian;

  (5) A person who has a durable power of attorney for health care; or

  (6) A person who is designated in a written advance directive;

  provided that an appointed representative shall include an "authorized representative" as used in the federal Patient Protection and Affordable Care Act. See Hawaii Revised Statutes 432E-1

• benefits: means those health care services to which an enrollee is entitled under the terms of a health benefit plan. See Hawaii Revised Statutes 432E-1
• Certification: means a determination by a health carrier or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness. See Hawaii Revised Statutes 432E-1
• Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. See Hawaii Revised Statutes 432E-1
• Commissioner: means the insurance commissioner. See Hawaii Revised Statutes 432E-1
• Contract: A legal written agreement that becomes binding when signed.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Emergency services: means services provided to an enrollee when the enrollee has symptoms of sufficient severity, including severe pain, such that a layperson could reasonably expect, in the absence of medical treatment, to result in placing the enrollee's health or condition in serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, or death. See Hawaii Revised Statutes 432E-1
• Enrollee: means a person who enters into a contractual relationship under or who is provided with health care services or benefits through a health benefit plan. See Hawaii Revised Statutes 432E-1
• 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.
• External review: means a review of an adverse determination (including a final adverse determination) conducted by an independent review organization pursuant to this chapter. See Hawaii Revised Statutes 432E-1
• 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, and rehabilitation and other therapeutic health settings. See Hawaii Revised Statutes 432E-1
• Fiduciary: A trustee, executor, or administrator.
• Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier or its designated utilization review organization at the completion of the health carrier's internal grievance process procedures, or an adverse determination with respect to which the internal appeals process is deemed to have been exhausted under section 432E-33(b). See Hawaii Revised Statutes 432E-1
• Health benefit plan: means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay or reimburse any of the costs of health care services. See Hawaii Revised Statutes 432E-1
• Health care professional: means an individual licensed, accredited, or certified to provide or perform specified health care services in the ordinary course of business or practice of a profession consistent with state law. See Hawaii Revised Statutes 432E-1
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Hawaii Revised Statutes 432E-1
• Health carrier: means an entity subject to the insurance laws and rules 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 a sickness and accident insurance company, a health maintenance organization, a mutual benefit society, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health care services. See Hawaii Revised Statutes 432E-1
• Independent review organization: means an independent entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Hawaii Revised Statutes 432E-1
• Internal review: means the review under § 432E-5 of an enrollee's complaint by a health carrier. See Hawaii Revised Statutes 432E-1
• Medical necessity: means a health intervention that meets the criteria enumerated in section 432E-1. See Hawaii Revised Statutes 432E-1
• Medical or scientific evidence: means evidence found in the following sources:

  (1) 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;

  (2) 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's National Library of Medicine for indexing in Index Medicus and Elsevier Science Ltd. See Hawaii Revised Statutes 432E-1

• provider: means a health care professional. See Hawaii Revised Statutes 432E-1
• Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. ^{Source: FDIC}
• Retrospective review: means a review of medical necessity conducted after services that 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 Hawaii Revised Statutes 432E-1
• Reviewer: means an independent reviewer with clinical expertise either employed by or contracted by an independent review organization to perform external reviews. See Hawaii Revised Statutes 432E-1
• 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 necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. See Hawaii Revised Statutes 432E-1
• Utilization review organization: means an entity that conducts utilization review other than a health carrier performing a review for its own health benefit plans. See Hawaii Revised Statutes 432E-1