Section 22-B6099. DEFINITIONS

 

6099.1The following terms shall have the meanings ascribed below:

 

Act - means the Health Benefits Plan Members Bill of Rights Act of 1998, effective April 27, 1999, D.C. Code, 2001 Ed. §§44-301.01 to 44-304.01.

 

Adverse decision - means a determination made by an insurer, or its designee, that an admission, availability of care, continued stay, or other health care service is or is not a covered benefit; and if it is a covered benefit, that it has been reviewed and does not meet the insurer's requirements for medical necessity, appropriateness, health care settings, level of care or effectiveness, and the requested service is therefore denied, reduced, limited, delayed or terminated.

 

Certificate - means a letter indicating that the Independent Review Organization is registered with the Department of Health.

 

Director - means the Director, District of Columbia Department of Health

 

Emergency medical condition - means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:

 

(a)Placing the health of the individual in serious jeopardy;

 

(b)Serious impairment of bodily functions; or

 

(c)Serious dysfunction of any bodily organ or part.

 

Evidence of coverage - means a statement of the essential features and covered services of the health care plan, which is given to the member by the insurer or by the group contract holder.

 

Grievance - means a written request by a member or member representative for review of a decision of an insurer to deny, reduce, limit, terminate or delay covered health care services to a member.

 

Grievance decision - means a determination accepting or denying the basis or requested remedy of the grievance.

 

Health benefits plan - means a group or individual insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar group arrangement provided by an insurer or subcontracting facility of an insurer for the purpose of providing, paying for, or reimbursing expenses for health related services. "Health benefits plan" does not include disability income or accident only insurance.

 

Health care services - means items or services provided under the supervision of a physician or other person trained or licensed to render health care necessary for the prevention, care, diagnosis, or treatment of human disease, pain, injury, deformity or other physical or mental condition, including the following: preadmission, outpatient, inpatient, and post discharge care; home care; physician care; nursing care; medical care provided by interns or residents in training; other paramedical care; ambulance care and service; bed and board; drugs; supplies; appliances; equipment; laboratory services; any form of diagnostic imaging or therapeutic radiological services; and services mandated under the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Act of 1986, effective February 28, 1987 (D.C. Code, 2001 Ed. §§31-3101 to 31-3111).

 

Health related services - means services related to the direct delivery of health care services designed to diagnose or treat an illness, injury or medical condition.

 

Independent Review Organization (IRO) - means an impartial, certified health entity engaged by the Director to review any adverse grievance decision by an insurer, including an insurer's decision to deny, terminate, or limit covered health care services.

 

Insurer - means an individual, partnership, corporation, association, fraternal benefit association, hospital and medical services corporation, health maintenance organization, or other business entity that issues, amends, or renews group or individual health insurance policies or contracts, including health maintenance organization membership contracts, in the District.

 

Medically necessary care - means the care which, in the opinion of the treating physician, is reasonably needed to:

 

(a)Prevent the onset or worsening of an illness, condition, or disability;

 

(b)Establish a diagnosis;

 

(c)Provide palliative, curative, or restorative treatment for physical and/or mental health conditions; and

 

(d)Assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

 

Member - means an individual who is enrolled in a health benefits plan.

 

Member representative - means any person acting on behalf of a member with the member's written consent.

 

Urgent medical condition - means a condition which, if non-treated within 24 hours, could reasonably be expected to result in:

 

(a)Placing the health of the individual in serious jeopardy;

 

(b)Serious impairment to bodily function; or

 

(c)Serious dysfunction of any bodily organ or part.

 

source

Final Rulemaking published at 47 DCR 229 (January 14, 2000).