Michigan Laws > Chapter 550 > Act 251 of 2000 – Patient’s Right to Independent Review Act
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Terms Used In Michigan Laws > Chapter 550 > Act 251 of 2000 - Patient's Right to Independent Review Act
- Adverse determination: means a determination by a health carrier or its designee 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 on 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 Michigan Laws 550.1903
- Ambulatory review: means utilization review of health care services performed or provided in an outpatient setting. See Michigan Laws 550.1903
- Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
- Authorized representative: means any of the following:
(i) A person to whom a covered person has given express written consent to represent the covered person in an external review. See Michigan Laws 550.1903benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Michigan Laws 550.1903 Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions. See Michigan Laws 550.1903 Certification: means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness. See Michigan Laws 550.1903 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 Michigan Laws 550.1903 Concurrent review: means utilization review conducted during a patient's hospital stay or course of treatment. See Michigan Laws 550.1903 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. Covered person: means a policyholder, subscriber, member, enrollee, or other individual participating in a health benefit plan. See Michigan Laws 550.1903 Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries. Department: means the department of insurance and financial services. See Michigan Laws 550.1903 Director: means the director of the department. See Michigan Laws 550.1903 Discharge planning: means the formal process for determining, before discharge from a facility, the coordination and management of the care that a patient receives following discharge from the facility. See Michigan Laws 550.1903 Disclose: means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information. See Michigan Laws 550.1903 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. Expedited internal grievance: means an expedited grievance under section 2213(1)(l) of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.1903 Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth in section 2213 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.1903 Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006. Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of covered health care services. See Michigan Laws 550.1903 Health care professional: means an individual licensed, certified, registered, or otherwise authorized to engage in a health profession under parts 161 to 183 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.1903 Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Michigan Laws 550.1903 Health carrier: means a person that is subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, 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 nonprofit health care corporation, a nonprofit dental care corporation operating under 1963 PA 125, MCL 550. See Michigan Laws 550.1903 health facility: means :
(i) A facility or agency or a part of a facility or agency that is licensed or authorized under parts 201 to 217 of the public health code, 1978 PA 368, MCL 333. See Michigan Laws 550.1903Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to 1 or more of the following:
(i) The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family. See Michigan Laws 550.1903in writing: shall be construed to include printing, engraving, and lithographing; except that if the written signature of a person is required by law, the signature shall be the proper handwriting of the person or, if the person is unable to write, the person's proper mark, which may be, unless otherwise expressly prohibited by law, a clear and classifiable fingerprint of the person made with ink or another substance. See Michigan Laws 8.3q Independent review organization: means a person that conducts independent external reviews of adverse determinations. See Michigan Laws 550.1903 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 any of the following sources:
(i) 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 Michigan Laws 550.1903Partnership: 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: means an individual or a corporation, partnership, association, joint venture, joint stock company, trust, unincorporated organization, or similar entity, or any combination of these. See Michigan Laws 550.1903 Prospective review: means utilization review conducted before an admission or a course of treatment. See Michigan Laws 550.1903 Protected health information: means health information that identifies an individual who is the subject of the information or with respect to which there is a reasonable basis to believe that the information could be used to identify an individual. See Michigan Laws 550.1903 provider: means a health care professional or a health facility. See Michigan Laws 550.1903 Retrospective review: means a review of medical necessity 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 Michigan Laws 550.1903 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 service to assess the clinical necessity and appropriateness of the initial proposed health service. See Michigan Laws 550.1903 state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o United States: shall be construed to include the district and territories. See Michigan Laws 8.3o 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 Michigan Laws 550.1903 Utilization review organization: means a person that conducts utilization review, other than a health carrier performing a review for its own health plans. See Michigan Laws 550.1903