Terms Used In Hawaii Revised Statutes 432E-35

• 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

• 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
• 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
• 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
• 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
• provider: means a health care professional. 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