Definitions. For purposes of this subchapter, the following
terms have the meanings indicated, except where the context clearly
indicates otherwise:
(1) Administrative denial--A denial of a claim that
is not an adverse determination, including, but not limited to, denials
of claims for noncovered benefits, duplicate claims, incorrect billing,
and because an individual is not an enrollee.
(2) Adverse determination--A determination by a health
benefit plan or utilization review agent that health care services
or benefits provided or proposed to be provided to an enrollee are
not medically necessary, appropriate, or are experimental or investigational.
Consistent with Insurance Code Chapter 1369, concerning Benefits Related
to Prescription Drugs and Devices and Related Services, the following
are adverse determinations:
(A) a denial of a fail-first (or step therapy) protocol
exception request; and
(B) an issuer's refusal to treat the drug as a covered
benefit, if an enrollee's physician has determined that a drug is
medically necessary and the drug is not included in the enrollee's
plan formulary.
(3) Aggregate lifetime dollar limit--A dollar limitation
on the total amount of specified benefits that may be paid under a
health benefit plan for any coverage unit.
(4) Allowed amount--The dollar amount covered under
the plan for a particular service or benefit, including the amount
of cost sharing owed by the enrollee and the amount to be paid by
the plan. This term refers both to the contracted amount for in-network
services or benefits and the amount designated by the plan for out-of-network
services or benefits.
(5) Annual dollar limit--A dollar limitation on the
total amount of specified benefits that may be paid in a 12-month
period under a health benefit plan for any coverage unit.
(6) Applied behavior analysis--The design, implementation,
and evaluation of instructional and environmental modifications to
produce socially significant improvements in human behavior that is
consistent with the practice of applied behavior analysis as addressed
in Occupations Code §506.003.
(7) Approved claim--A claim for a service or benefit
that is determined, at initial review or upon receipt of additional
information, to be covered and payable at the plan's allowed amount.
(8) Concurrent review--A form of utilization review
for ongoing health care or for an extension of treatment beyond previously
approved health care.
(9) Coverage unit--Coverage unit as described in §21.2408(a)(4)
of this title (relating to Parity Requirements with Respect to Financial
Requirements and Treatment Limitations).
(10) Cumulative financial requirements--Financial requirements
that determine whether or to what extent benefits are provided based
on accumulated amounts and include deductibles and out-of-pocket maximums.
Cumulative financial requirements do not include aggregate lifetime
or annual dollar limits.
(11) Cumulative quantitative treatment limitations--Treatment
limitations that determine whether or to what extent benefits are
provided based on accumulated amounts, such as annual or lifetime
day or visit limits. The term includes a deductible, a copayment,
coinsurance, or another out-of-pocket expense or annual or lifetime
limit, or another financial requirement.
(12) Denial--An administrative denial or an adverse
determination.
(13) Fail-first or step therapy--A treatment protocol
that requires an enrollee to use a prescription drug or sequence of
prescription drugs other than the drug that the enrollee's physician
recommends for the enrollee's treatment before the health benefit
plan provides coverage for the recommended drug.
(14) Financial requirements--Plan deductibles, copayments,
coinsurance, or out-of-pocket maximums. Financial requirements do
not include aggregate lifetime or annual dollar limits.
(15) Health benefit plan or plan--A plan that is subject
to Insurance Code Chapter 1355, Subchapter F, concerning Coverage
for Mental Health Conditions and Substance Use Disorders.
(16) Independent review--A system for final administrative
review by an independent review organization (IRO) of an adverse determination
regarding the medical necessity, the appropriateness, or the experimental
or investigational nature of health care services or benefits.
(17) Individual market--Health benefit plans subject
to Insurance Code Chapter 1355, Subchapter F, that are bought on an
individual or family basis in which the contract holder is also personally
enrolled under the plan, other than in connection with a group health
plan.
(18) Internal appeal--A formal process by which an
enrollee, an individual acting on behalf of an enrollee, or an enrollee's
provider of record may request reconsideration of an adverse determination.
(19) Large group market--Health benefit plans subject
to Insurance Code Chapter 1355, Subchapter F, that are sold to groups
that have 51 or more members, whether through an employer or through
an association.
(20) Market type--Individual, small group, or large
group market.
(21) Medical or surgical (medical/surgical) benefit--A
benefit with respect to an item or service for medical conditions
or surgical procedures, as defined under the terms of the health benefit
plan and in accordance with applicable federal and state law, but
does not include mental health or substance use disorder benefits.
Any condition defined by a plan as being or as not being a medical/surgical
condition must be defined to be consistent with generally recognized
independent standards of current medical practice (for example, the
most recent edition of the ICD or state guidelines).
(22) Mental health benefit--A benefit with respect
to an item or service for a mental health condition, as defined under
the terms of a health benefit plan and in accordance with applicable
federal and state law. Any condition defined by a health benefit plan
as being or as not being a mental health condition must be defined
to be consistent with generally recognized independent standards of
current medical practice (for example, the most recent edition of
the Diagnostic and Statistical Manual of
Mental Disorders (DSM), the most recent edition of the ICD,
or state guidelines).
(23) NQTL--Nonquantitative treatment limitation.
(24) Peer-to-peer review or physician-to-physician
review--A utilization review process that may occur before an adverse
determination is issued by a utilization review agent, consistent
with Insurance Code §4201.206, concerning Opportunity to Discuss
Treatment Before Adverse Determination.
(25) Plan design--A plan's discrete package of benefits,
cost-sharing structure, provider network, plan type, quantitative
treatment limitations, and nonquantitative treatment limitations.
(26) Plan documents--All instruments under which a
plan is established or operated, including, but not limited to, policies,
certificates of coverage, contracts of insurance, evidences of coverage,
provider contracts, provider manuals, internal guidelines and procedures,
medical guidelines, and other documents used in making claims determinations
and conducting utilization reviews. Instruments under which the plan
is established or operated includes the processes, strategies, evidentiary
standards, and other factors used to apply a nonquantitative treatment
limitation (NQTL) with respect to medical/surgical benefits and mental
health/substance use disorder (MH/SUD) benefits under the plan.
(27) Plan type--A preferred provider organization (PPO)
plan, exclusive provider organization (EPO) plan, health maintenance
organization (HMO) plan, health maintenance organization-point of
service (HMO-POS) plan, and indemnity policy.
(28) Preauthorization or prior authorization--A utilization
review process in which an issuer conditions coverage of a health
care service, benefit, or prescription drug on the issuer's approval
of the provider's request to provide an enrollee the service, benefit,
or drug. For purposes of this rule:
(A) preauthorization includes reauthorization of services
or benefits that had received preauthorization, but for which the
approval period has lapsed;
(B) preauthorization does not include utilization review
needed to reauthorize ongoing services or benefits (concurrent review);
and
(C) a request for preauthorization is one received
during the reporting period, regardless of the date the claim is incurred.
(29) Prescription drugs--Drugs covered under a plan's
prescription drug benefit.
(30) QTL--Quantitative treatment limitation.
(31) Reasonable method--To determine the dollar amount
or the per member per month amount of plan payments for the substantially
all or predominant analyses required by §21.2408 of this title,
reasonable methods are:
Cont'd... |
