NOTE: §1260.41 Paragraphs (1)-(9) enacted by Acts 2023, No. 312, eff. Jan. 1, 2024.
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 R.S. 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 R.S. 22:2392.
(8) "Healthcare provider" or "provider" means an ambulance service as defined in
R.S. 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 R.S.
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.