As used in this chapter:

(1)  “Adverse benefit determination” means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse determination if the review agent and provider are in agreement regarding the decision. Adverse benefit determinations include:

(i)  “Administrative adverse benefit determinations,” meaning any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual’s eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and

(ii)  “Non-administrative adverse benefit determinations,” meaning any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity‘s formulary.

(2)  “Appeal” or “internal appeal” means a subsequent review of an adverse benefit determination upon request by a claimant to include the beneficiary or provider to reconsider all or part of the original adverse benefit determination.

(3)  “Authorized representative” means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary.

(4)  “Beneficiary” means a policy holder subscriber, enrollee, or other individual participating in a health benefit plan.

(5)  “Benefit determination” means a decision to approve or deny a request to provide or make payment for a healthcare service.

(6)  “Certificate” means a certificate granted by the commissioner to a healthcare entity meeting the requirements of this chapter.

(7)  “Commissioner” means the commissioner of the office of the health insurance commissioner.

(8)  “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, authorized representative, or provider. The appeal of an adverse benefit determination is not considered a complaint.

(9)  “Delegate” means a person or entity authorized pursuant to a delegation of authority or directly or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or regulations or guidance promulgated thereunder.

(10)  “Emergency services” or “emergent services” means those resources provided in the event of the sudden onset of a medical, behavioral health, or other health condition that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of any bodily organ or part.

(11)  “Health benefit plan” or “health plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services.

(12)  “Healthcare entity” means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing health insurance, accident and sickness insurance, health benefits, or healthcare services.

(13)  “Healthcare services” means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary’s health benefit plan.

(14)  “Most-favored-rate clause” means a provision in a provider contract whereby the rates or fees to be paid by a healthcare entity are fixed, established, or adjusted to be equal to or lower than the rates or fees paid to the provider by any other healthcare entity.

(15)  “Network” means the group or groups of participating providers providing healthcare services under a network plan.

(16)  “Network plan” means a health benefit plan or health plan that either requires a beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the providers managed, owned, under contract with, or employed by the healthcare entity.

(17)  “Office” means the office of the health insurance commissioner.

(18)  “Professional provider” means an individual provider or healthcare professional licensed, accredited, or certified to perform specified healthcare services consistent with state law and who provides these healthcare services and is not part of a separate facility or institutional contract.

(19)  “Provider” means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider, or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.

(20)  “Tiered network” means a network that identifies and groups some or all types of providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, or provider access requirements, or any combination thereof, apply for the same services.