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

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

"Appointed representative" means aperson who is expressly permitted by the enrollee or who has the power underHawaii 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 forhealth care; or

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

"Commissioner" means the insurancecommissioner.

"Complaint" means an expression ofdissatisfaction, either oral or written.

"Emergency services" means servicesprovided to an enrollee when the enrollee has symptoms of sufficient severitythat 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 organor part, or death.

"Enrollee" means a person who entersinto a contractual relationship or who is provided with health care services orbenefits through a managed care plan.

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

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

"Health care provider" means anindividual licensed or certified to provide health care in the ordinary courseof 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 independentdecisions;

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

(3)  Applies evidence-based decisionmaking;

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

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

(6)  Has effective systems in place to conduct areview.

"Internal review" means the reviewunder 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, includingbut not limited to an insurer governed by chapter 431, a mutual benefit societygoverned by chapter 432, a health maintenance organization governed by chapter432D, a preferred provider organization, a point of service organization, ahealth insurance issuer, a fiscal intermediary, a payor, a prepaid health careplan, and any other mixed model, that provides for the financing or delivery ofhealth care services or benefits to enrollees through:

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

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

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

"Medical director" means the personwho is authorized under a managed care plan and who makes decisions for theplan denying or allowing payment for medical treatments, services, or suppliesbased on medical necessity or other appropriate medical or health plan benefitstandards.

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

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