Terms Used In Rhode Island General Laws > Chapter 27-18.9 - Benefit Determination and Utilization Review Act

• 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. See Rhode Island General Laws 27-18.9-2
• 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.
• Authorization: means a review by a review agent, performed according to this chapter, concluding that the allocation of healthcare services ordered by a provider, given or proposed to be given to a beneficiary, was approved or authorized. See Rhode Island General Laws 27-18.9-2
• 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. See Rhode Island General Laws 27-18.9-2
• Beneficiary: means a policy-holder subscriber, enrollee, or other individual participating in a health-benefit plan. See Rhode Island General Laws 27-18.9-2
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• Benefit determination: means a decision to approve or deny a request to provide or make payment for a healthcare service or treatment. See Rhode Island General Laws 27-18.9-2
• Certificate: means a certificate granted by the commissioner to a review agent meeting the requirements of this chapter. See Rhode Island General Laws 27-18.9-2
• Claim: means a request for plan benefit(s) made by a claimant in accordance with the healthcare entity's reasonable procedures for filing benefit claims. See Rhode Island General Laws 27-18.9-2
• Claimant: means a healthcare entity participant, beneficiary, and/or authorized representative who makes a request for plan benefit(s). See Rhode Island General Laws 27-18.9-2
• Commissioner: means the health insurance commissioner. See Rhode Island General Laws 27-18.9-2
• Concurrent claim: means a request for a plan benefit(s) by a claimant that is for an ongoing course of treatment or services over a period of time or for the number of treatments. See Rhode Island General Laws 27-18.9-2
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• 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 a non-administrative adverse benefit determination (including final internal adverse benefit determination) conducted pursuant to an applicable external review process performed by an independent review organization. See Rhode Island General Laws 27-18.9-2
• External review decision: means a determination by an independent review organization at the conclusion of the external review. See Rhode Island General Laws 27-18.9-2
• 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. See Rhode Island General Laws 27-18.9-2
• 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 pursuant to chapter 62 of Title 42, 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 a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. See Rhode Island General Laws 27-18.9-2
• 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. See Rhode Island General Laws 27-18.9-2
• in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
• 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. See Rhode Island General Laws 27-18.9-2
• IRO: means an entity that conducts independent external reviews of adverse benefit determinations or final internal adverse benefit determinations. See Rhode Island General Laws 27-18.9-2
• Judgement: The official decision of a court finally determining the respective rights and claims of the parties to a suit.
• 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.
• Network: means the group or groups of participating providers providing healthcare services under a network plan. See Rhode Island General Laws 27-18.9-2
• 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. See Rhode Island General Laws 27-18.9-2
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Office: means the office of the health insurance commissioner. See Rhode Island General Laws 27-18.9-2
• Oversight: Committee review of the activities of a Federal agency or program.
• person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
• Pre-service claim: means the request for a plan benefit(s) by a claimant prior to a service being rendered and is not considered a concurrent claim. See Rhode Island General Laws 27-18.9-2
• 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 healthcare services and is not part of a separate facility or institutional contract. See Rhode Island General Laws 27-18.9-2
• 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. See Rhode Island General Laws 27-18.9-2
• 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.
• Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
• Review agent: means a person or healthcare entity performing benefit determination reviews that is either employed by, affiliated with, under contract with, or acting on behalf of a healthcare entity. See Rhode Island General Laws 27-18.9-2
• Same or similar specialty: means a practitioner who has the appropriate training and experience that is the same or similar as the attending provider in addition to experience in treating the same problems to include any potential complications as those under review. See Rhode Island General Laws 27-18.9-2
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Therapeutic interchange: means the interchange or substitution of a drug with a dissimilar chemical structure within the same therapeutic or pharmacological class that can be expected to have similar outcomes and similar adverse reaction profiles when given in equivalent doses, in accordance with protocols approved by the president of the medical staff or medical director and the director of pharmacy. See Rhode Island General Laws 27-18.9-2
• Transcript: A written, word-for-word record of what was said, either in a proceeding such as a trial or during some other conversation, as in a transcript of a hearing or oral deposition.
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Utilization review: means the prospective, concurrent, or retrospective assessment of the medical necessity and/or appropriateness of the allocation of healthcare services of a provider, given or proposed to be given, to a beneficiary. See Rhode Island General Laws 27-18.9-2