374.500. Definitions.

MISSOURI STATUTES AND CODES

Definitions.

374.500. As used in sections 374.500 to 374.515, the following termsmean:

(1) "Certificate", a certificate of registration granted by thedepartment of insurance, financial institutions and professional registrationto a utilization review agent;

(2) "Director", the director of the department of insurance, financialinstitutions and professional registration;

(3) "Enrollee", an individual who has contracted for or who participatesin coverage under a health insurance policy, an employee welfare benefit plan,a health services corporation plan or any other benefit program providingpayment, reimbursement or indemnification for health care costs for himself oreligible dependents or both himself and eligible dependents. The term"enrollee" shall not include an individual who has health care coveragepursuant to a liability insurance policy, workers' compensation insurancepolicy, or medical payments insurance issued as a supplement to a liabilitypolicy;

(4) "Provider of record", the physician or other licensed practitioneridentified to the utilization review agent as having primary responsibilityfor the care, treatment and services rendered to an enrollee;

(5) "Utilization review", a set of formal techniques designed to monitorthe use of, or evaluate the clinical necessity, appropriateness, efficacy, orefficiency of, health care services, procedures, or settings. Techniques mayinclude ambulatory review, prospective review, second opinion, certification,concurrent review, case management, discharge planning or retrospectivereview. Utilization review shall not include elective requests forclarification of coverage;

(6) "Utilization review agent", any person or entity performingutilization review, except:

(a) An agency of the federal government;

(b) An agent acting on behalf of the federal government, but only to theextent that the agent is providing services to the federal government; or

(c) Any individual person employed or used by a utilization review agentfor the purpose of performing utilization review services, including, but notlimited to, individual nurses and physicians, unless such individuals areproviding utilization review services to the applicable benefit plan, pursuantto a direct contractual relationship with the benefit plan;

(d) An employee health benefit plan that is self-insured and qualifiedpursuant to the federal Employee Retirement Income Security Act of 1974, asamended;

(e) A property-casualty insurer or an employee or agent working onbehalf of a property-casualty insurer;

(f) A health carrier, as defined in section 376.1350, RSMo, that isperforming a review of its own health plan;

(7) "Utilization review plan", a summary of the utilization reviewprocedures of a utilization review agent.