Terms Used In Louisiana Revised Statutes > Title 22 > Chapter 18 > Part I - Title, Definitions, and Licensure

• Adverse determination: means any of the following:

              (a) A determination by a health insurance issuer or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer'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 not provided or made, in whole or in part, for the benefit. See Louisiana Revised Statutes 22:2392

• Ambulatory review: means utilization review of health care services performed or provided in an outpatient setting. See Louisiana Revised Statutes 22:2392
• Authorized representative: means any of the following:

              (a) A person to whom a covered person has given express written consent to represent the covered person for purposes of this Chapter. See Louisiana Revised Statutes 22:2392

• Axle: means the common axis of rotation of one or more wheels whether power-driven or freely rotating, and whether in one or more segments, and regardless of the number of wheels carried thereon. See Louisiana Revised Statutes 32:1
• barber college: shall include a school of barbering, college of barbering, barber school, barber college, and any other place or institution for the instruction or training of persons to engage in the practice of barbering. See Louisiana Revised Statutes 37:355
• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Louisiana Revised Statutes 22:2392
• Best evidence: means evidence based on any of the following:

              (a) Randomized clinical trials. See Louisiana Revised Statutes 22:2392

• Business day: means a day of normal business operation other than federally recognized holidays. See Louisiana Revised Statutes 22:2392
• Cargo: means the items or freight to be moved, including items placed on or in a vehicle, towed by a vehicle, or a vehicle itself. See Louisiana Revised Statutes 32:1
• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Louisiana Revised Statutes 22:2392
• Case-series: means an evaluation of a series of patients with a particular outcome, without the use of a control group. See Louisiana Revised Statutes 22:2392
• Combination of vehicles: means every group of two or more vehicles howsoever joined together which are drawn or propelled by a single motor vehicle. See Louisiana Revised Statutes 32:1
• Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• 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. See Louisiana Revised Statutes 22:2392
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Louisiana Revised Statutes 22:2392
• Department: means the Department of Transportation and Development. See Louisiana Revised Statutes 32:1
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility. See Louisiana Revised Statutes 22:2392
• Emergency medical condition: means a medical condition manifesting itself by symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy. See Louisiana Revised Statutes 22:2392
• entity: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Louisiana Revised Statutes 22:2392
• 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.
• 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. See Louisiana Revised Statutes 22:2392
• 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, rehabilitation and other therapeutic health settings, and inpatient hospice facilities. See Louisiana Revised Statutes 22:2392
• Final adverse determination: means an adverse determination, including medical judgment, involving a covered benefit that has been upheld by a health insurance issuer, or its designee utilization review organization, at the completion of the health insurance issuer's internal claims and appeals process procedures provided pursuant to Louisiana Revised Statutes 22:2392
• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Louisiana Revised Statutes 22:2392
• Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Louisiana Revised Statutes 22:2392
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Louisiana Revised Statutes 22:2392
• Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to any of 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. See Louisiana Revised Statutes 22:2392

• Health insurance issuer: means an entity subject to the insurance laws and regulations 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 through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
• Highway: means the entire width between the boundary lines of every way or place of whatever nature publicly maintained and open to the use of the public for the purpose of vehicular travel, including bridges, causeways, tunnels and ferries; synonymous with the word "street". See Louisiana Revised Statutes 32:1
• Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• 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 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. See Louisiana Revised Statutes 22:2392

• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
• Prospective review: means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health insurance issuer's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision. See Louisiana Revised Statutes 22:2392
• Protected health information: means either of the following:

              (a) Health information that identifies an individual who is the subject of the information. See Louisiana Revised Statutes 22:2392

• provider: means a health care professional or a facility. See Louisiana Revised Statutes 22:2392
• Rescission: means cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. See Louisiana Revised Statutes 22:2392
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Retrospective review: means a utilization review conducted after services 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 Louisiana Revised Statutes 22:2392
• Second opinion: means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical or medical necessity and appropriateness of the initial proposed health care service. See Louisiana Revised Statutes 22:2392
• Secretary: means the secretary of the Department of Transportation and Development or his delegated or authorized representative. See Louisiana Revised Statutes 32:1
• Special permit: means a written authorization to move or operate on a highway a vehicle or combination of vehicles with indivisible load of size and/or weight exceeding the limits prescribed for vehicles in regular operation. See Louisiana Revised Statutes 32:1
• Subpoena: A command to a witness to appear and give testimony.
• Truck: means every motor propelled single vehicle for the conveyance of property or things for hauling purposes and having one front steering axle and one rear or load carrying axle. See Louisiana Revised Statutes 32:1
• Urgent care request: means :

              (a) A request for a health care service or course of treatment with respect to which the time periods for making a non-urgent care request determination either:

              (i) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function. See Louisiana Revised Statutes 22:2392

• Utilization review: means a set of formal techniques designed to monitor the use of or evaluate the clinical or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
• Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to Louisiana Revised Statutes 22:2392
• Vehicle: means every device by which persons or things may be transported upon a public highway or bridge, except devices moved by human power or used exclusively upon stationary rails or tracks. See Louisiana Revised Statutes 32:1