§432E-1  Definitions.  As used in this
chapter, unless the context otherwise requires:



"Appeal" means a request from an
enrollee to change a previous decision made by the managed care plan.



"Appointed representative" means a
person who is expressly permitted by the enrollee or who has the power under
Hawaii law to make health care decisions on behalf of the enrollee, including:



(1)  A court-appointed legal guardian;



(2)  A person who has a durable power of attorney for
health care; or



(3)  A person who is designated in a written advance
directive.



"Commissioner" means the insurance
commissioner.



"Complaint" means an expression of
dissatisfaction, either oral or written.



"Emergency services" means services
provided to an enrollee when the enrollee has symptoms of sufficient severity
that a layperson could reasonably expect, in the absence of medical treatment,
to result in placing the enrollee's health or condition in serious jeopardy,
serious impairment of bodily functions, serious dysfunction of any bodily organ
or part, or death.



"Enrollee" means a person who enters
into a contractual relationship or who is provided with health care services or
benefits through a managed care plan.



"Expedited appeal" means the internal
review of a complaint or an external review of the final internal determination
of an enrollee's complaint, which is completed within seventy-two hours after
receipt of the request for expedited appeal.



"External review" means an
administrative review requested by an enrollee under section 432E-6 of a
managed care plan's final internal determination of an enrollee's complaint.



"Health care provider" means an
individual licensed or certified to provide health care in the ordinary course
of business or practice of a profession.



"Health maintenance organization"
means a health maintenance organization as defined in section 432D-1.



"Independent review organization"
means an independent entity that:



(1)  Is unbiased and able to make independent
decisions;



(2)  Engages adequate numbers of practitioners with
the appropriate level and type of clinical knowledge and expertise;



(3)  Applies evidence-based decisionmaking;



(4)  Demonstrates an effective process to screen
external reviews for eligibility;



(5)  Protects the enrollee's identity from unnecessary
disclosure; and



(6)  Has effective systems in place to conduct a
review.



"Internal review" means the review
under section 432E-5 of an enrollee's complaint by a managed care plan.



"Managed care plan" means any plan,
regardless of form, offered or administered by any person or entity, including
but not limited to an insurer governed by chapter 431, a mutual benefit society
governed by chapter 432, a health maintenance organization governed by chapter
432D, a preferred provider organization, a point of service organization, a
health insurance issuer, a fiscal intermediary, a payor, a prepaid health care
plan, and any other mixed model, that provides for the financing or delivery of
health care services or benefits to enrollees through:



(1)  Arrangements with selected providers or provider
networks to furnish health care services or benefits; and



(2)  Financial incentives for enrollees to use
participating providers and procedures provided by a plan;



provided, that for the purposes of this chapter, an
employee benefit plan shall not be deemed a managed care plan with respect to
any provision of this chapter or to any requirement or rule imposed or
permitted by this chapter which is superseded or preempted by federal law.



"Medical director" means the person
who is authorized under a managed care plan and who makes decisions for the
plan denying or allowing payment for medical treatments, services, or supplies
based on medical necessity or other appropriate medical or health plan benefit
standards.



"Medical necessity" means a health
intervention as defined in section 432E-1.4.



"Participating provider" means a
licensed or certified provider of health care services or benefits, including
mental health services and health care supplies, that has entered into an
agreement with a managed care plan to provide those services or supplies to
enrollees. [L 1998, c 178, pt of §2; am L 1999, c 273, §2; am L 2000, c 250,
§3]