4-5 Vt. Code R. 3:10.100 - General provisions under the Department of Financial Regulation regulations

“General provisions under the Department of Financial Regulation regulations”

(1.1) Managed care organizations must comply with consumer protection and quality requirements.

(1.3)(A) “Managed care organizations” include health insurers, health maintenance organizations, preferred provider organizations, exclusive provider organizations, and mental health review agents.

(1.4) (A) “Adverse benefit determination” means a denial, reduction, termination or failure to provide or make payment that is based on: a determination of a participant's or beneficiary's eligibility to participate in a health benefit plan; the application of any utilization review; and a failure to cover an item or service because it is determined to be experimental or investigational or not medically necessary or appropriate.

(1.4)(G) “Clinical review criteria” means the written screening procedures, clinical protocols, practice guidelines and utilization management and review guidelines used by the managed care organization to determine the necessity and appropriateness of health care services.

(1.4) (I) “Concurrent review” means utilization review conducted during a managed care organization’s member's stay in a health care facility or other ongoing course of treatment.

(1.4) (U) “Grievance” means a complaint submitted by or on behalf of a member regarding the:

adverse benefit determination; availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters relating to the contractual relationship between a member and a managed care organization or the health insurer offering the health benefit plan.

(1.4) (FF) “Manage health care delivery” means to apply any design or mechanism to a health benefit plan to affect access to or the quality, coordination or cost of the health care available to members under the health benefit plan, including the use of any form of utilization management, pharmaceutical benefit management, networks, preferred providers or any other restrictions or incentives for members to use certain providers, and disease, care or case management.

(1.4) (RR) “Pharmaceutical benefit management program” (“PBMP”) means any mechanisms used to manage prescription drug benefits, including formularies, dose restrictions, prior or other authorization requirements, step therapy and substitution requirements.

(1.4) (SS) “Post-service review” means review of any claim for a benefit that is not a pre-service or concurrent review claim as defined by this rule.

(1.4) (TT) “Pre-service review” means review of any claim for a benefit with respect to which the terms of coverage condition receipt of the benefit on approval of the benefit in advance of obtaining health care.

(1.4) (JJJ) “Utilization management” means the set of organizational functions and related policies used by a managed care organization or pharmaceutical benefit management program to ensure that it is appropriately managing access to and the quality and cost of health care services, including prescription drug benefits, provided to its members.

(1.4) (KKK) “Utilization review” means a set of formal techniques designed to monitor the use, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings, including prescription drugs.

(1.4) (LLL) “Utilization review guidelines” mean the normative standards and clinical review criteria for resource utilization for various clinical conditions and medical services that are used by managed care organizations in deciding whether to approve or deny health care services.