SUBPART P. UTILIZATION REVIEW STANDARDS

§1260.41. Definitions

            For purposes of this Subpart, the following terms have the following meanings unless the context clearly indicates otherwise:

            (1) “Adverse determination” means a determination by a health insurance issuer or utilization review entity that an admission, availability of care, continued stay, or other healthcare service furnished or proposed to be furnished to an enrollee has been reviewed and, based upon the information provided, does not meet a health insurance issuer’s requirements for medical necessity, appropriateness, healthcare setting, or level of care or effectiveness, or is experimental or investigational, and the utilization review for the requested service is therefore denied, reduced, or terminated.

            (2) “Ambulatory review” means the same as the term is defined in La. Rev. Stat. 22:2392.

            (3) “Certification” means a determination by a health insurance issuer or a utilization review entity that an admission, availability of care, continued stay, or other healthcare service has been reviewed and, based on the information provided, satisfies the health insurance issuer’s requirements for medical necessity, appropriateness, healthcare setting, and level of care and effectiveness, and that payment will be made for that healthcare service, provided the patient is an enrollee of the health benefit plan at the time the service is provided.

            (4) “Clinical review criteria” means the written policies or screening procedures, drug formularies or lists of covered drugs, determination rules, decision abstracts, clinical protocols, medical protocols, practice guidelines, and any other criteria or rationale used by the health insurance issuer or utilization review entity to determine the necessity and appropriateness of healthcare services.

            (5) “Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.

            (6) “Healthcare facility” or “facility” means a facility or institution providing healthcare services including but not limited to a hospital or other licensed inpatient center; ambulatory surgical or treatment center; skilled nursing facility; inpatient hospice facility; residential treatment center; diagnostic, laboratory, or imaging center; or rehabilitation or other therapeutic health setting. A “healthcare facility” may include a base healthcare facility.

            (7) “Healthcare professional” means the same as the term is defined in La. Rev. Stat. 22:2392.

            (8) “Healthcare provider” or “provider” means an ambulance service as defined in La. Rev. Stat. 40:1131, a healthcare professional or a healthcare facility, or the agent or assignee of the professional or facility.

            (9) “Healthcare services” means services, items, supplies, or drugs for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

NOTE: Paragraph (10) enacted by Acts 2023, No. 333, eff. Jan. 1, 2024.

            (10)(a) “Health insurance issuer” means the same as the term is defined in La. Rev. Stat. 22:1019.1, except as provided in Subparagraph (b) of this Paragraph.

            (b) The provisions of this Subpart shall not apply to an entity that provides limited scope dental or vision benefits.

NOTE: Paragraphs (11)-(15) enacted by Acts 2023, No. 312, eff. Jan. 1, 2024.

            (11) “Prior authorization” means a determination by a health insurance issuer or person contracting with a health insurance issuer that healthcare services ordered by the provider for an enrollee are medically necessary and appropriate.

            (12) “Retrospective review” means a utilization review of medical necessity that is conducted after services have been provided to an enrollee 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.

            (13) “Urgent condition” means a condition which could immediately and seriously jeopardize the life or health of the patient or the patient’s ability to attain, maintain, or regain maximum function.

            (14) “Utilization review” means a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of healthcare services, procedures, or settings. Techniques for application include but are not limited to ambulatory review, second opinion, certification, concurrent review, case management, discharge planning, reviews to determine prior authorization, and retrospective review. “Utilization review” does not include elective requests for clarification of coverage.

            (15) “Utilization review entity” means an individual or entity that performs reviews to determine prior authorization for a health insurance issuer. A health insurance issuer or healthcare provider is a utilization review entity if it performs utilization review.

            Acts 2023, No. 312, §1, eff. Jan 1, 2024; Acts 2023, No. 333, §2, eff. Jan. 1, 2024.