Subchapter 3 - DEFINITIONS1. Appeal: A formal request to reconsider a determination not to certify an admission, extension of stay, or other medical service.2. Attending Physician: The physician with primary responsibility for the care provided to a patient in a hospital or other health care facility.3. Certificate: A certificate of registration granted by the Mississippi Department of Health to a private review agent, and is not transferable.4. Certification: A determination by a utilization review organization that an admission, extension of stay, or other medical service has been reviewed and based on the information provided, qualifies as medically necessary and appropriate under the medical review requirements of the applicable health benefit plan.5. Certification Number: The number assigned to each certified private review agent. This number is not transferable.6. Certified Private Review Agent: A private review agent who meets all the criteria for certification as set forth in these rules and regulations, has paid all current fees, and has been assigned a certification number.7. Concurrent Review: Utilization review conducted during a patient's hospital stay or course of treatment.8. Consulting Physician: A Medical Doctor, Doctor of Osteopathy, Dentist, Psychologist, Podiatrist or Chiropractor who possess the degree of skill ordinarily possessed and used by members of his or her profession in good standing, and actively engaged in the same type of practice and relevant specialty. The medical and osteopathy specialist shall be certified by the Boards within the American Board of Medical Specialists or the American Board of Osteopathy.9. Department: The Mississippi Department of Health.10. Director: The Director of the Division of Health Facilities Licensure and Certification of the Mississippi Department of Health.11. Enrollee: The individual who has elected to contract for, or participate in, a health benefit plan for their self and/or their dependents.12. Expedited Appeal: A request for additional review of a utilization review organization's determination not to certify an admission, extension of stay, or other medical service. An expedited appeal request may be called a reconsideration request by some utilization review organizations.13. Hospital: An institution which is primarily engaged in providing to inpatients, by or under the supervision of physicians, diagnostic services and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation services for the rehabilitation of injured, disabled or sick persons, and also, means a place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment and illness, disease, injury or deformity, or a place devoted primarily to providing obstetrical or other medical, surgical or nursing care of individuals, whether or not any such place be organized or operated for profit and whether any such place be publicly or privately owned. The term "Hospital" does not include convalescent or boarding homes, children's homes, homes for the aged or other like establishments where room and board only are provided, nor does it include offices or clinics where patients are not regularly kept as bed patients.14. Patient: The intended recipient of the proposed health care, his/her representative, and/or the enrollee.15. Physician Advisor: A physician representing the claim administrator/utilization review organization who provides advice on whether to certify an admission, extension of stay, or other medical service as being medically necessary and appropriate.16. Private Review Agent: A non-hospital affiliated person or entity performing utilization review on behalf of: a. An employer or employees in the State of Mississippi; orb. A third party that provides or administers hospital and medical benefits to citizens of this state, including: a health maintenance organization issued a certificate of authority under and by virtue of the laws of the State of Mississippi, or a health insurer, nonprofit health service plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state.17. Provider Utilization Review Representative: The person(s) in a physician's office or hospital designated by the physician or hospital to provide the necessary information to complete the review process.18. Review Criteria: The written policies, decision rules, medical protocols, or guides used by the utilization review organization to determine certification [e.g., Appropriateness Evaluation Protocol (AEP) and Intensity of Service, Severity of Illness, Discharge, and Appropriateness Screens (ISD-A)].19. Utilization Review: A system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. More specifically, utilization review refers to pre-service determination of the medical necessity or appropriateness of services to be rendered in a hospital setting either on an inpatient or outpatient basis, when such determination results in approval or denial of payment for the services. It includes both prospective and concurrent review and may include retrospective review under certain circumstances.20. Utilization Review Plan: A description of the utilization review procedures of a private review agent.