[334B-2] Definitions. As used in this chapter:

"Director" means the director of health.

"Health care provider" means any person, corporation, facility, or institution licensed by this State to provide health care services, including but not limited to a physician, hospital or other health care facility, nurse, psychologist, or substance abuse counselor, and officer, employee, or agent of such provider acting in the course and scope of employment or agency related to health care services.

"Health care services" means diagnosis, treatment, medical or psychological evaluation or advice, or other acts as permissible under the health care licensing statutes of this State.

"Physician" means a person licensed to practice medicine under chapter 453.

"Psychologist" means a person licensed to practice psychology under chapter 465.

"Review agent" means a hospital or nonhospital-affiliated person or entity performing utilization review or managed care that is either affiliated with, under contract with, or acting on behalf of:

(1) A business entity in this State; or

(2) A third party that provides or administers hospital, medical, psychological, or other health care benefits to citizens of this State, including a health insurer, nonprofit health service plan, health insurance service organization, health maintenance organization, or preferred provider organization authorized to offer health insurance policies or contracts in this State.

"Utilization review" or "managed care" means a system for reviewing the appropriate and efficient allocation of mental health, alcohol, or drug abuse treatment services given or proposed to be given to a patient or group of patients for the purpose of recommending or determining whether such services should be reimbursed, covered, or provided by an insurer, plan or other entity or person.

"Utilization review plan" means a description of the criteria and standards governing utilization review or managed care activities performed by a review agent. [L 1991, c 95, pt of 1]

 

 

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