Section Ins 2001.03 - Definitions(a) For the purposes of this part, the definitions appearing under RSA 420-E:1 shall apply whenever any word or phrase defined under RSA 420-E:1 is used in this part.(b) With respect to the following words or phrases used in this part, but which are not defined under RSA 420-E:1, the following definitions shall apply:(1) "Beneficiary" means any person or his or her covered dependent who is receiving or is proposed to receive a health care service covered under a health care benefit plan for which utilization review is to be conducted;(2) "Business days" means all days other than weekends and legal holidays;(3) "Confidential medical information" means medical information that is not intended to be disclosed to third persons other than those present to further the interest of the beneficiary in a consultation, examination, or interview, or persons, including members of the beneficiary's family, who are participating in the diagnosis and treatment of the beneficiary under the direction of a physician, psychotherapist, or other licensed health care provider;(4) "Emergency" means a medical case involving a critical, life-threatening condition requiring medical or surgical care which, if not received immediately, would result in risk to life;(5) "Emergency notification requirement" means the duty imposed upon a beneficiary by the beneficiary's health care benefit plan to notify a medical utilization review entity in the event of the beneficiary's receipt of emergency medical treatment;(6) "Exempt organization" means an insurer, nonprofit service organization, health maintenance organization, preferred provider organization, or an employee of an exempt organization;(7) "Health care benefit plan" means a contract or other agreement by which an insurer, a nonprofit service organization, a health maintenance organization, a third party administrator, or an employer arranges for or is the payor for health care services;(8) "Medical utilization review entity" means any person, partnership, or corporation that provides utilization review services. The term includes "utilization review entity";(9) "Medical utilization review services" means those services that are performed in the conduct of utilization review as defined under RSA 420-E:1, IV. The term includes "utilization review services";(10) "National committee for quality assurance (NCQA)" means the independent, nonprofit organization based in Washington, D.C. whose primary purpose is to assess and report on the quality of managed care plans, including health maintenance organizations;(11) "Reasonable explanation" means that sufficient information is provided to the beneficiary to enable the beneficiary to effectively exercise the right of appeal;(12) "Utilization review accreditation commission (URAC)" means the voluntary, nonprofit organization based in Washington, D.C. that provides a centralized review and accreditation process.N.H. Admin. Code § Ins 2001.03
#5931, eff 12-5-94, EXPIRED: 12-5-00
New. #7683, eff 6-1-02; ss by #9721-A, eff 6-11-10
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12545, Effective 6/11/2018, Expires 6/11/2028.