Section 27-3A-3

Definitions.

As used in this chapter, the following words and phrases shall have the following meanings:

(1) DEPARTMENT. The Alabama Department of Public Health.

(2) ENROLLEE. 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 eligible dependents of the individual.

(3) PROVIDER. A health care provider duly licensed or certified by the State of Alabama.

(4) UTILIZATION REVIEW. A system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within this state. The term does not include elective requests for clarification of coverage.

(5) UTILIZATION REVIEW AGENT. Any person or entity, including the State of Alabama, performing a utilization review, except the following:

a. An agency of the federal government.

b. An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government.

c. The internal quality assurance program of a hospital.

d. An employee of a utilization review agent.

e. Health maintenance organizations licensed and regulated by the state, but only to the extent of providing a utilization review to their own members.

f. Any entity that has a current accreditation from the Utilization Review Accreditation Commission (URAC). However, entities with current URAC accreditation shall file a URAC certification with the department annually.

g. An entity performing utilization reviews or bill audits, or both, exclusively for workers' compensation claims pursuant to Section 25-5-312. If an entity also performs services for claims other than workers' compensation, it shall be considered a private review agent subject to this chapter for those claims.

h. An entity performing utilization reviews or bill audits, or both, exclusively for the Medicaid Agency.

i. A person performing utilization reviews or bill audits, or both, exclusively for their company's health plan, independent of a utilization review company.

j. An insurance company licensed by the State of Alabama performing utilization reviews or bill audits, or both, exclusively for their company's health plan, independent of a utilization review company.

k. The Peer Review Committee of the Alabama State Chiropractic Association.

(Acts 1994, 1st Ex. Sess., No. 94-786, p. 80, §3.)