26.1-26.4-02. Definitions
For purposes of this chapter, unless the context requires otherwise:
1. "Commissioner" means the insurance commissioner.
2. "Emergency medical condition" means a medical condition of recent onset and
severity, including severe pain, that would lead a prudent layperson acting reasonably
and possessing an average knowledge of health and medicine to believe that the
absence of immediate medical attention could reasonably be expected to result in
serious impairment to bodily function, serious dysfunction of any bodily organ or part,
or would place the person's health, or with respect to a pregnant woman the health of
the woman or her unborn child, in serious jeopardy.
3. "Emergency services" means health care services, supplies, or treatments furnished
or required to screen, evaluate, and treat an emergency medical condition.
4. "Enrollee" means an individual who has contracted for or who participates in coverage
under an insurance policy, a health maintenance organization contract, a health
service corporation contract, an employee welfare benefit plan, a hospital or medical
services plan, or any other benefit program providing payment, reimbursement, or
indemnification for health care costs for the individual or the individual's eligible
dependents.
5. "Health care insurer" includes an insurance company as defined in section 26.1-02-01,
a health service corporation as defined in section 26.1-17-01, a health maintenance
organization as defined in section 26.1-18.1-01, and a fraternal benefit society as
defined in section 26.1-15.1-02.
6. "Provider of record" means the physician or other licensed practitioner identified to the
utilization review agent as having primary responsibility for the care, treatment, and
services rendered to an individual.
7. "Retrospective" means utilization review of medical necessity which is conducted after
services have been provided to a patient, but does not include the review of a claim
that is limited to an evaluation of reimbursement levels, veracity of documentation,
accuracy of coding, or adjudication for payment.
8. "Utilization review" means a system for prospective, retrospective, and concurrent
review of the necessity and appropriateness in the allocation of health care resources
and services that are subject to state insurance regulation and which are given or
proposed to be given to an individual within this state. Utilization review does not
include elective requests for clarification of coverage.
9. "Utilization review agent" means any person or entity performing utilization review,
except:
a. An agency of the federal government; or
b. An agent acting on behalf of the federal government or the department of health
and human services, but only to the extent that the agent is providing services to
the federal government or the department of health and human services.
