Section 4530.30 Definitions

Section 4530.30  Definitions

"Act"

means the Health Carrier External Review Act [215 ILCS 180].

"Adverse Determination"

means:

A determination by a health

carrier or its designee utilization review organization that, based upon the

information provided, a request for a benefit under the health carrier's health

benefit plan, upon application of any utilization review technique, does not

meet the health carrier's requirements for medical necessity, appropriateness,

health care setting, level of care, or effectiveness or is determined to be

experimental or investigational, and the requested benefit is therefore denied,

reduced or terminated, or payment is not provided or made, in whole or part,

for the benefit;

The denial, reduction or

termination of, or failure to provide or make payment, in whole or in part,

for, a benefit based on a determination by a health carrier or its designee

utilization review organization that a preexisting condition was present before

the effective date of coverage; or

A rescission of coverage

determination, which does not include a cancellation or discontinuance of

coverage that is attributable to a failure to timely pay required premiums or

contributions towards the cost of coverage.

"Authorized

Representative" means:

A person to whom a covered person

has given express written consent to represent the covered person for purposes

of the Act;

A person authorized by law to

provide substituted consent for a covered person;

A family member of the covered

person or the covered person's treating health care professional when the

covered person is unable to provide consent;

A health care provider when the

covered person's health benefit plan requires that a request for a benefit

under the plan be initiated by the health care provider; or

In the case of an urgent care

request, a health care provider with knowledge of the covered person's medical

condition

the covered person's treating health care professional when the

covered person is unable to provide consent;

A health care provider when the

covered person's health benefit plan requires that a request for a benefit

under the plan be initiated by the health care provider; or

In the case of an urgent care

request, a health care provider with knowledge of the covered person's medical

condition.

"Best

Evidence" means evidence based on:

Randomized

clinical trials;

If randomized clinical trials are

not available, then cohort studies or case-control studies;

If the prior two

items are not available, then case-series; or

If the prior

three items are not available, then expert opinion.

"Case-control Study"

means a retrospective evaluation of two groups of patients with different

outcomes to determine which specific interventions the patients received.

"Case-series" means an

evaluation of a series of patients with a particular outcome, without the use

of a control group.

"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.

"Cohort Study" means a

prospective evaluation of 2 groups of patients with only one group of patients

receiving specific intervention.

"Code" means the

Illinois Insurance Code [215 ILCS 5].

"Concurrent Review"

means a review conducted during a patient's stay or course of treatment in a

facility, the office of a health care professional, or other inpatient or

outpatient health care setting.

"Covered Benefits" or

"Benefits" means those health care services to which a covered person

is entitled under the terms of a health benefit plan.

"Covered Person" means a

policyholder, subscriber, enrollee, or other individual participating in a

health benefit plan.

"Director"

means the Director of the Illinois Department of Insurance

al, or other inpatient or

outpatient health care setting.

"Covered Benefits" or

"Benefits" means those health care services to which a covered person

is entitled under the terms of a health benefit plan.

"Covered Person" means a

policyholder, subscriber, enrollee, or other individual participating in a

health benefit plan.

"Director"

means the Director of the Illinois Department of Insurance.

"Emergency Medical

Condition" means a medical condition manifesting itself by acute symptoms

of sufficient severity, including, but not limited to, severe pain, such that a

prudent layperson who possesses an average knowledge of health and medicine

could reasonably expect the absence of immediate medical attention to result

in:

placing the health of the

individual or, with respect to a pregnant woman, the health of the woman or her

unborn child, in serious jeopardy;

serious impairment to bodily

functions; or

serious dysfunction of any bodily

organ or part.

"Evidence-based

Standard" means the conscientious, explicit and judicious use of the

current best evidence based on an overall systematic review of the research in

making decisions about the care of individual patients.

"Expert Opinion" means a

belief or an interpretation by specialists with experience in a specific area

about the scientific evidence pertaining to a particular service, intervention,

or therapy.

"Facility" means an

institution providing health care services or a health care setting.

"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 by the Managed Care Reform and Patient Rights

Act [215 ILCS 134].

"Health Benefit Plan"

means a policy, contract, certificate, plan, or agreement offered or issued by

a health carrier to provide, deliver, arrange for, pay for, or reimburse any of

the costs of health care services

review

organization, at the completion of the health carrier's internal grievance

process procedures as set forth by the Managed Care Reform and Patient Rights

Act [215 ILCS 134].

"Health Benefit Plan"

means a policy, contract, certificate, plan, or agreement offered or issued by

a health carrier to provide, deliver, arrange for, pay for, or reimburse any of

the costs of health care services.

"Health Care Provider"

or "Provider" means a physician, hospital facility, or other health

care practitioner licensed, accredited, or certified to perform specified

health care services consistent with State law, responsible for recommending

health care services on behalf of a covered person.

"Health Care Services"

means services for the diagnosis, prevention, treatment, cure, or relief of a

health condition, illness, injury, or disease.

"Health Carrier" means

an entity 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, or any other entity providing a

plan of health insurance, health benefits, or health care services.

"Health carrier" also means Limited Health Service Organizations

(LHSO) and Voluntary Health Service Plans.

"Health Information"

means information or data, whether oral or recorded in any form or medium, and

personal facts or information about events or relationships that relate to:

The past, present, or future

physical, mental, or behavioral health or condition of an individual or a

member of the individual's family;

The provision

of health care services to an individual; or

Payment for

the provision of health care services to an individual.

"Independent Review

Organization" or "IRO" means an entity that conducts independent

external reviews of adverse determinations and final adverse determinations

hysical, mental, or behavioral health or condition of an individual or a

member of the individual's family;

The provision

of health care services to an individual; or

Payment for

the provision of health care services to an individual.

"Independent Review

Organization" or "IRO" means an entity that conducts independent

external reviews of adverse determinations and final adverse determinations.

"Medical Necessity"

means health care services and supplies provided by a health care provider,

appropriate to the evaluation and treatment of a disease, condition, illness or

injury and consistent with the applicable standard of care, including the

evaluation of experimental and/or investigational services, procedures, drugs

or devices.

"Medical or

Scientific Evidence" means evidence found in the following sources:

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;

Peer-reviewed medical literature,

including literature relating to therapies reviewed and approved by a qualified

institutional review board, biomedical compendia, and other medical literature

that meets the criteria of the National Institutes of Health's Library of

Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd

ew by experts who are not part of the

editorial staff;

Peer-reviewed medical literature,

including literature relating to therapies reviewed and approved by a qualified

institutional review board, biomedical compendia, and other medical literature

that meets the criteria of the National Institutes of Health's Library of

Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for

indexing in Excerpta Medicus (EMBASE);

Medical journals recognized by the

Secretary of Health and Human Services under section 1861(t)(2) of the federal

Social Security Act (42 USC 1861(t)(2));

The following

standard reference compendia:

The American

Hospital Formulary Service Drug Information;

Drug Facts and

Comparisons;

The American Dental Association

Accepted Dental Therapeutics; and

The United States Pharmacopoeia Drug Information;

Findings, studies, or research

conducted by or under the auspices of federal government agencies and

nationally recognized federal research institutes, including:

The federal

Agency for Healthcare Research and Quality;

The National

Institutes of Health;

The National

Cancer Institute;

The National

Academy of Sciences;

The Centers for

Medicare & Medicaid Services;

The federal Food

and Drug Administration; and

Any national board recognized by

the National Institutes of Health for the purpose of evaluating the medical

value of health care services; or

Any other medical or scientific

evidence that is comparable to the sources listed in this definition.

Medical necessity

determinations for substance use disorders shall be made in accordance with

appropriate patient placement criteria established by the American Society of

Addiction Medicine

[215 ILCS 5/370c(b)(3)].

"Member"

means a covered person as defined by this Part.

"Person" means an

individual, a corporation, a partnership, an association, a joint venture, a

joint stock company, a trust, an unincorporated organization, any similar

entity, or any combination of the foregoing

th

appropriate patient placement criteria established by the American Society of

Addiction Medicine

[215 ILCS 5/370c(b)(3)].

"Member"

means a covered person as defined by this Part.

"Person" means an

individual, a corporation, a partnership, an association, a joint venture, a

joint stock company, a trust, an unincorporated organization, any similar

entity, or any combination of the foregoing.

"Prospective Review"

means a review conducted prior to an admission or the provision of a health

care service or a course of treatment in accordance with a health carrier's requirement

that the health care service or course of treatment, in whole or in part, be

approved prior to its provision.

"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.

"Randomized Clinical

Trial" means a controlled, prospective study of patients that have been

randomized into an experimental group and a control group at the beginning of

the study with only the experimental group of patients receiving a specific

intervention, which includes study of the groups for variables and anticipated

outcomes over time.

"Retrospective Review"

means any review of a request for a benefit that is not a concurrent or

prospective review request. "Retrospective Review" does not include

the review of a claim that is limited to veracity of documentation or accuracy

of coding.

"Utilization Review"

means the evaluation of the medical necessity, appropriateness, and efficiency

of the use of health care services, procedures, and facilities.

"Utilization Review

Organization" means a utilization review program as defined in the Managed

Care Reform and Patient Rights Act.