44-5433.

Terms, defined.

For purposes of the Ensuring Transparency in Prior Authorization Act, unless the context otherwise requires:

(1) Adverse determination has the same meaning as in section 44-1303;

(2) Clinical peer means a health care provider in the same, or in a similar, specialty that typically manages the medical condition or health care service under review;

(3) Clinical review criteria has the same meaning as in section 44-1303;

(4) Department means the Department of Insurance;

(5) Emergency health care services means health care services medically necessary to screen and stabilize a patient in connection with an emergency medical condition until the health care provider determines such individual is able to travel using nonmedical transportation;

(6) Emergency medical condition has the same meaning as in section 44-1303;

(7) Enrollee means an individual who is enrolled in a health benefit plan, including covered dependents;

(8) General acute hospital has the same meaning as in section 71-412;

(9) Health benefit plan has the same meaning as in section 44-1303;

(10) Health care provider has the same meaning as in section 44-1303;

(11) Health care services has the same meaning as in section 44-1303;

(12) Health carrier has the same meaning as in section 44-1303, except that health carrier does not include a managed care agent;

(13) Medically necessary has the same meaning as in section 44-6845;

(14) Notice means communication delivered either electronically or through the United States Postal Service or a common carrier;

(15) Physician means an individual licensed under the Medicine and Surgery Practice Act to practice medicine and surgery or osteopathic medicine and surgery or an individual with an equivalent license from another United States jurisdiction;

(16) Prior authorization means the process by which a health carrier or utilization review agent makes a determination that a requested admission, extension of stay, or health care service has been reviewed and, based on the information provided, satisfies the health carrier's or utilization review agent's requirements for reimbursement under the applicable health benefit plan;

(17) Urgent health care service means a health care service with respect to which the application of the time periods prescribed under the Ensuring Transparency in Prior Authorization Act for making a nonexpedited prior authorization could, in the opinion of a physician with knowledge of the enrollee's medical condition:

(a) Seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; or

(b) Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review; and

(18) Utilization review agent has the same meaning as in section 44-5418.