33-37-101. Definitions. For the purposes of this chapter, the following definitions apply:
     (1) "Adverse determination" means a determination by a health carrier, a managed care entity, or an agent of a health carrier or managed care entity that the health care services furnished or proposed to be furnished to an enrollee are not appropriate and medically necessary.
     (2) "Appropriate and medically necessary" means the standard for health care services as determined by health care providers in accordance with the prevailing practices and standards of the health care profession and community.
     (3) "Department" means the department of public health and human services provided for in 2-15-2201.
     (4) "Enrollee" has the meaning provided for a covered person as defined in 33-36-103.
     (5) "Health benefit plan" has the meaning provided in 33-36-103.
     (6) "Health care provider" has the meaning provided in 33-36-103.
     (7) "Health care treatment decision" means a determination made when medical services are actually provided by a health carrier or other managed care entity and that affects the quality of the diagnosis, care, or treatment provided to the insureds or enrollees of a health benefit plan. The term does not include a decision by a health carrier or managed care entity to deny payment or coverage for services based on the provisions of a policy, contract, certificate, or agreement.
     (8) "Health carrier" has the meaning provided for in 33-36-103.
     (9) (a) "Managed care entity" means a health carrier or any entity that delivers, administers, or assumes risk for health care services with systems or techniques to control or influence the quality, accessibility, utilization, or costs and prices of health care services to a defined enrollee population.
     (b) The term does not include an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer.
     (10) "Peer" means a health care provider actively practicing a health care profession in this state who has substantially the same education and training, who provides substantially the same range of health care services, and who has the same license or certification to practice as the health care provider whose practice, professional services, or activities on behalf of the enrollee are being considered, reviewed, evaluated, or judged.

     History: En. Sec. 1, Ch. 482, L. 1999.