Definitions

In this Act: (1) Adverse determination The term adverse determination means a decision by a medicare administrative contractor, Medicare Advantage plan, or prescription drug plan that administers prior authorization programs under the Medicare program under title XVIII of the Social Security Act or such plan that the health care services furnished or proposed to be furnished to an individual entitled to benefits or enrolled under the Medicare program are not medically necessary, or are experimental or investigational; and benefit coverage under such program or plan for such services is therefore denied, reduced, or terminated. (2) Authorization The term authorization means a determination by a medicare administrative contractor, Medicare Advantage plan, or prescription drug plan that administers prior authorization programs under the Medicare program under title XVIII of the Social Security Act or such plan that a health care service has been reviewed and, based on the information provided, satisfies the utilization review entity’s requirements for medical necessity and appropriateness and that payment will be made under the Medicare program under title XVIII of the Social Security Act or such plan for that health care service. (3) Clinical criteria The term clinical criteria means the written policies, written screening procedures, drug formularies, or lists of covered drugs, decision rules, decision abstracts, clinical protocols, practice guidelines, and medical protocols used by a medicare administrative contractor, Medicare Advantage plan, or prescription drug plan to determine the necessity and appropriateness of health care services. (4) Final adverse determination The term final adverse determination means an adverse determination that has been upheld by a medicare administrative contractor, Medicare Advantage plan, or prescription drug plan at the completion of the contractor’s appeals process. (5) Health care service The term health care service means a health care item, service, procedure, treatment, or prescription drug provided by a facility licensed in the State involved or provided by a doctor of medicine, a doctor of osteopathic medicine, or a health care professional licensed in such State. (6) Medically necessary health care service The term medically necessary health care services means health care services that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is— (A) in accordance with generally accepted standards of medical practice; (B) clinically appropriate in terms of type, frequency, extent, site, and duration; and (C) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider. (7) Medicare Administrative Contractor The term medicare administrative contractor means a medicare administrative contractor with a contract under section 1874A of the Social Security Act (42 U.S.C. 1395kk–1). (8) Medicare Advantage plan The term Medicare Advantage plan means a Medicare Advantage plan under part C of title XVIII of the Social Security Act. (9) Preauthorization The term preauthorization — (A) means the process by which a medicare administrative contractor, Medicare Advantage plan, or prescription drug plan determines the medical necessity or medical appropriateness of health care services for which benefits are otherwise provided under the Medicare program under title XVIII of the Social Security Act or such plan prior to the rendering of such health care services, including preadmission review, pretreatment review, utilization, and case management; and (B) includes any requirement that a patient or health care provider notify the Centers for Medicare & Medicaid Services prior to providing a health care service. (10) Prescription drug plan The term prescription drug plan means a prescription drug plan under part D of title XVIII of the Social Security Act.