As used in this part, the term:(1) “Adverse determination” means a coverage determination by an organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the organization’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and coverage for the requested service is therefore denied, reduced, or terminated.
(2) “Agency” means the Agency for Health Care Administration.
(3) “Clinical peer” means a health care professional in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.
(4) “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the organization to determine, for coverage purposes, the necessity and appropriateness of health care services.
(5) “Complaint” means any expression of dissatisfaction by a subscriber, including dissatisfaction with the administration, claims practices, or provision of services, which relates to the quality of care provided by a provider pursuant to the organization’s contract and which is submitted to the organization or to a state agency. A complaint is part of the informal steps of a grievance procedure and is not part of the formal steps of a grievance procedure unless it is a grievance as defined in subsection (10).
(6) “Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.
(7) “Emergency medical condition” means:(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:1. That there is inadequate time to effect safe transfer to another hospital prior to delivery;
2. That a transfer may pose a threat to the health and safety of the patient or fetus; or
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(8) “Emergency services and care” means medical screening, examination, and evaluation by a physician or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of a hospital.
(9) “Geographic area” means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers.
(10) “Grievance” means a written complaint submitted by or on behalf of a subscriber to an organization or a state agency regarding the:(a) Availability, coverage for the delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b) Claims payment, handling, or reimbursement for health care services; or
(c) Matters pertaining to the contractual relationship between a subscriber and an organization.
A grievance does not include a written complaint submitted by or on behalf of a subscriber eligible for a grievance and appeals procedure provided by an organization pursuant to contract with the Federal Government under Title XVIII of the Social Security Act.
(11) “Health care services” means comprehensive health care services, as defined in s. 641.19, when applicable to a health maintenance organization, and means basic services, as defined in s. 641.402, when applicable to a prepaid health clinic. (12) “Minimum services” includes any of the following: emergency care, inpatient hospital services, physician care, ambulatory diagnostic treatment, and preventive health care services.
(13) “Organization” means any health maintenance organization as defined in s. 641.19 and any prepaid health clinic as defined in s. 641.402. (14) “Provider” means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state. To submit or pursue a grievance on behalf of a subscriber, a provider must previously have been directly involved in the treatment or diagnosis of the subscriber.
(15) “Retrospective review” means a review, for coverage purposes, of medical necessity conducted after services have been provided to a patient.
(16) “Subscriber” means an individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care services.
(17) “Urgent grievance” means an adverse determination when the standard timeframe of the grievance procedure would seriously jeopardize the life or health of a subscriber or would jeopardize the subscriber’s ability to regain maximum function.
