FIRSTREGULARSESSION
HOUSEBILLNO.1207
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVEBUSH.
2674H.01I JOSEPHENGLER,ChiefClerk
ANACT
Torepealsection376.1350,RSMo,andtoenactinlieuthereoftwonewsectionsrelatingto
priorauthorizationofinpatientpsychiatrichospitalservices.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Section376.1350,RSMo,isrepealedandtwonewsectionsenactedinlieu
2thereof,tobeknownassections376.1350and376.1368,toreadasfollows:
376.1350.Forpurposesofsections376.1350to[376.1390] 376.1389, thefollowing
2termsmean:
3 (1)"Adversedetermination",adeterminationbyahealthcarrierorautilization
4reviewentitythatanadmission,availabilityofcare,continuedstayorotherhealthcare
5servicefurnishedorproposedtobefurnishedtoanenrolleehasbeenreviewedand,based
6upontheinformationprovided,doesnotmeettheutilizationreviewentityorhealthcarrier's
7requirementsformedicalnecessity,appropriateness,healthcaresetting,levelofcareor
8effectiveness,orareexperimentalorinvestigational,andthepaymentfortherequested
9serviceisthereforedenied,reducedorterminated;
10 (2)"Ambulatoryreview",utilizationreviewofhealthcareservicesperformedor
11providedinanoutpatientsetting;
12 (3)"Casemanagement",acoordinatedsetofactivitiesconductedforindividual
13patientmanagementofserious,complicated,protractedorotherhealthconditions;
14 (4)"Certification",adeterminationbyahealthcarrierorautilizationreviewentity
15thatanadmission,availabilityofcare,continuedstayorotherhealthcareservicehasbeen
16reviewedand,basedontheinformationprovided,satisfiesthehealthcarrier'srequirements
17formedicalnecessity,appropriateness,healthcaresetting,levelofcareandeffectiveness,and
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 18thatpaymentwillbemadeforthathealthcareserviceprovidedthepatientisanenrolleeof
19thehealthbenefitplanatthetimetheserviceisprovided;
20 (5)"Clinicalpeer",aphysicianorotherhealthcareprofessionalwhoholdsa
21nonrestrictedlicenseinastateoftheUnitedStatesandinthesameorsimilarspecialtyas
22typicallymanagesthemedicalcondition,procedureortreatmentunderreview;
23 (6)"Clinicalreviewcriteria",thewrittenpolicies,writtenscreeningprocedures,drug
24formulariesorlistsofcovereddrugs,determinationrules,decisionabstracts,clinical
25protocols,medicalprotocols,practiceguidelines,andanyothercriteriaorrationaleusedby
26thehealthcarrierorutilizationreviewentitytodeterminethenecessityandappropriatenessof
27healthcareservices;
28 (7)"Concurrentreview",utilizationreviewconductedduringapatient'shospitalstay
29orcourseoftreatment;
30 (8)"Coveredbenefit"or"benefit",ahealthcareservicethatanenrolleeisentitled
31underthetermsofahealthbenefitplan;
32 (9)"Director",thedirectorofthedepartmentofcommerceandinsurance;
33 (10)"Dischargeplanning",theformalprocessfordetermining,priortodischarge
34fromafacility,thecoordinationandmanagementofthecarethatapatientreceivesfollowing
35dischargefromafacility;
36 (11)"Drug",anysubstanceprescribedbyalicensedhealthcareprovideractingwithin
37thescopeoftheprovider'slicenseandthatisintendedforuseinthediagnosis,mitigation,
38treatmentorpreventionofdisease.Thetermincludesonlythosesubstancesthatareapproved
39bytheFDAforatleastoneindication;
40 (12)"Emergencymedicalcondition",thesuddenand,atthetime,unexpectedonsetof
41ahealthconditionthatmanifestsitselfbysymptomsofsufficientseverity,regardlessofthe
42finaldiagnosisthatisgiven,thatwouldleadaprudentlayperson,possessinganaverage
43knowledgeofmedicineandhealth,tobelievethatimmediatemedicalcareisrequired,which
44mayinclude,butshallnotbelimitedto:
45 (a)Placingtheperson'shealthinsignificantjeopardy;
46 (b)Seriousimpairmenttoabodilyfunction;
47 (c)Seriousdysfunctionofanybodilyorganorpart;
48 (d)Inadequatelycontrolledpain;or
49 (e)Withrespecttoapregnantwomanwhoishavingcontractions:
50 a.Thatthereisinadequatetimetoeffectasafetransfertoanotherhospitalbefore
51delivery;or
52 b.Thattransfertoanotherhospitalmayposeathreattothehealthorsafetyofthe
53womanorunbornchild;
HB1207 2 54 (13)"Emergencyservice",ahealthcareitemorservicefurnishedorrequiredto
55evaluateandtreatanemergencymedicalcondition,whichmayinclude,butshallnotbe
56limitedto,healthcareservicesthatareprovidedinalicensedhospital'semergencyfacilityby
57anappropriateprovider;
58 (14)"Enrollee",apolicyholder,subscriber,coveredpersonorotherindividual
59participatinginahealthbenefitplan;
60 (15)"FDA",thefederalFoodandDrugAdministration;
61 (16)"Facility",aninstitutionprovidinghealthcareservicesorahealthcaresetting,
62includingbutnotlimitedtohospitalsandotherlicensedinpatientcenters,ambulatorysurgical
63ortreatmentcenters,skillednursingcenters,residentialtreatmentcenters,diagnostic,
64laboratoryandimagingcenters,andrehabilitationandothertherapeutichealthsettings;
65 (17)"Grievance",awrittencomplaintsubmittedbyoronbehalfofanenrollee
66regardingthe:
67 (a)Availability,deliveryorqualityofhealthcareservices,includingacomplaint
68regardinganadversedeterminationmadepursuanttoutilizationreview;
69 (b)Claimspayment,handlingorreimbursementforhealthcareservices;or
70 (c)Matterspertainingtothecontractualrelationshipbetweenanenrolleeandahealth
71carrier;
72 (18)"Healthbenefitplan",apolicy,contract,certificateoragreemententeredinto,
73offeredorissuedbyahealthcarriertoprovide,deliver,arrangefor,payfor,orreimburseany
74ofthecostsofhealthcareservices;exceptthat,healthbenefitplanshallnotincludeany
75coveragepursuanttoliabilityinsurancepolicy,workers'compensationinsurancepolicy,or
76medicalpaymentsinsuranceissuedasasupplementtoaliabilitypolicy;
77 (19)"Healthcareprofessional",aphysicianorotherhealthcarepractitionerlicensed,
78accreditedorcertifiedbythestateofMissouritoperformspecifiedhealthservicesconsistent
79withstatelaw;
80 (20)"Healthcareprovider"or"provider",ahealthcareprofessionalorafacility;
81 (21)"Healthcareservice",aserviceforthediagnosis,prevention,treatment,cureor
82reliefofahealthcondition,illness,injuryordisease,includingbutnotlimitedtotheprovision
83ofdrugsordurablemedicalequipment;
84 (22)"Healthcarrier",anentitysubjecttotheinsurancelawsandregulationsofthis
85statethatcontractsorofferstocontracttoprovide,deliver,arrangefor,payfororreimburse
86anyofthecostsofhealthcareservices,includingasicknessandaccidentinsurancecompany,
87ahealthmaintenanceorganization,anonprofithospitalandhealthservicecorporation,orany
88otherentityprovidingaplanofhealthinsurance,healthbenefitsorhealthservices;except
89thatsuchplanshallnotincludeanycoveragepursuanttoaliabilityinsurancepolicy,workers'
HB1207 3 90compensationinsurancepolicy,ormedicalpaymentsinsuranceissuedasasupplementtoa
91liabilitypolicy;
92 (23)"Healthindemnityplan",ahealthbenefitplanthatisnotamanagedcareplan;
93 (24)"Inpatientpsychiatrichospitalservices",inpatienthospitalservices
94furnishedtoaninpatientofamentalhealthfacility,asdefinedinsection632.005,for
95thetreatmentofamentaldisorderormentalillness,assuchtermsaredefinedinsection
96630.005;
97 (25)"Managedcareplan",ahealthbenefitplanthateitherrequiresanenrolleetouse,
98orcreatesincentives,includingfinancialincentives,foranenrolleetouse,healthcare
99providersmanaged,owned,undercontractwithoremployedbythehealthcarrier;
100 [(25)] (26)"Participatingprovider",aproviderwho,underacontractwiththehealth
101carrierorwithitscontractororsubcontractor,hasagreedtoprovidehealthcareservicesto
102enrolleeswithanexpectationofreceivingpayment,otherthancoinsurance,co-paymentsor
103deductibles,directlyorindirectlyfromthehealthcarrier;
104 [(26)] (27)"Peer-reviewedmedicalliterature",apublishedscientificstudyina
105journalorotherpublicationinwhichoriginalmanuscriptshavebeenpublishedonlyafter
106havingbeencriticallyreviewedforscientificaccuracy,validityandreliabilitybyunbiased
107independentexperts,andthathasbeendeterminedbytheInternationalCommitteeofMedical
108JournalEditorstohavemettheuniformrequirementsformanuscriptssubmittedto
109biomedicaljournalsorispublishedinajournalspecifiedbytheUnitedStatesDepartmentof
110HealthandHumanServicespursuanttoSection1861(t)(2)(B)oftheSocialSecurityAct(42
111U.S.C.Section1395x),asamended,asacceptablepeer-reviewedmedicalliterature.Peer-
112reviewedmedicalliteratureshallnotincludepublicationsorsupplementstopublicationsthat
113aresponsoredtoasignificantextentbyapharmaceuticalmanufacturingcompanyorhealth
114carrier;
115 [(27)] (28)"Person",anindividual,acorporation,apartnership,anassociation,ajoint
116venture,ajointstockcompany,atrust,anunincorporatedorganization,anysimilarentityor
117anycombinationoftheforegoing;
118 [(28)] (29)"Priorauthorization",acertificationmadepursuanttoapriorauthorization
119review,ornoticeasrequiredbyahealthcarrierorutilizationreviewentitypriortothe
120provisionofhealthcareservices;
121 [(29)] (30)"Priorauthorizationreview",utilizationreviewconductedpriortoan
122admissionoracourseoftreatment,includingbutnotlimitedtopre-admissionreview,
123pretreatmentreview,utilizationreview,andcasemanagement;
124 [(30)] (31)"Retrospectivereview",utilizationreviewofmedicalnecessitythatis
125conductedafterserviceshavebeenprovidedtoapatient,butdoesnotincludethereviewofa
HB1207 4 126claimthatislimitedtoanevaluationofreimbursementlevels,veracityofdocumentation,
127accuracyofcodingoradjudicationforpayment;
128 [(31)] (32)"Secondopinion",anopportunityorrequirementtoobtainaclinical
129evaluationbyaproviderotherthantheoneoriginallymakingarecommendationfora
130proposedhealthservicetoassesstheclinicalnecessityandappropriatenessoftheinitial
131proposedhealthservice;
132 [(32)] (33)"Stabilize",withrespecttoanemergencymedicalcondition,thatno
133materialdeteriorationoftheconditionislikelytoresultoroccurbeforeanindividualmaybe
134transferred;
135 [(33)] (34)"Standardreferencecompendia":
136 (a)TheAmericanHospitalFormularyService-DrugInformation;or
137 (b)TheUnitedStatesPharmacopoeia-DrugInformation;
138 [(34)] (35)"Utilizationreview",asetofformaltechniquesdesignedtomonitorthe
139useof,orevaluatetheclinicalnecessity,appropriateness,efficacy,orefficiencyof,health
140careservices,procedures,orsettings.Techniquesmayincludeambulatoryreview,prior
141authorizationreview,secondopinion,certification,concurrentreview,casemanagement,
142dischargeplanningorretrospectivereview.Utilizationreviewshallnotincludeelective
143requestsforclarificationofcoverage;
144 [(35)] (36)"Utilizationreviewentity",autilizationreviewagentasdefinedinsection
145374.500,oranindividualorentitythatperformspriorauthorizationreviewsforahealth
146carrierorhealthcareprovider.Ahealthcarrierorhealthcareproviderisautilizationreview
147entityifitperformspriorauthorizationreview.
376.1368.Ahealthcarriershallnotrequirepriorauthorizationofinpatient
2psychiatrichospitalservices.
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