1. (1) "Carrier" means a person providing health insurance or disability income insurance including:

   1. (a) an insurance company;
   2. (b) a prepaid hospital or medical care plan;
   3. (c) a health maintenance organization;
   4. (d) a multiple employer welfare arrangement;
   5. (e) a managed care organization; and
   6. (f) any other person providing health insurance or disability income insurance under Title 31A, Insurance Code.
2. (2) "Claimant" means an insured or an insured's legal representative, including an immediate family member designated by the insured.

3. (3) "Consumer representative" means an employee of a carrier who represents a consumer perspective, if the employee is not:

   1. (a) the individual who made the adverse benefit determination; or
   2. (b) subordinate to the individual who made the adverse benefit determination.

4. (4)(a) "Health insurance" means insurance providing:

   1. (i) a health care benefit; or

      1. (ii) payment of an incurred health care expense.
   2. (b) Health insurance includes an accident and health insurance policy allowing for an adverse benefit determination on the basis of medical necessity, rather than a specified event.

5. (5)(a) "Independent review organization" means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.

   1. (b) The independent review organization chosen may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with a health insurance plan, a national, state, or local trade association of health insurance plans, and a national, state, or local trade association of health care providers.

6. (6)(a) "Medical necessity" means a health care service or product that a prudent health care professional would provide to a patient to prevent, diagnose, or treat an illness, injury, disease, or its symptoms in a manner that is:

   1. (i) in accordance with generally accepted standards of medical practice in the United States;

      1. (ii) clinically appropriate in terms of type, frequency, extent, site, and duration;
      2. (iii) not primarily for the convenience of the patient, physician, or other health care provider; and
      3. (iv) covered under the policy.

   2. (b) If a medical question-of-fact exists, "medical necessity" shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

      1. (i) For an intervention not yet in widespread use, the effectiveness is based on scientific evidence.

      2. (ii) For an established intervention, the effectiveness is based on:

         1. (A) scientific evidence;
         2. (B) professional standards; and
         3. (C) expert opinion.

7. (7)(a) "Scientific evidence" means:

   1. (i) a scientific study published in or accepted by a medical journal that meets nationally recognized standards for scientific manuscripts and that submits its published articles for review by experts who are not part of the editorial staff; or

      1. (ii) a finding, study, or research conducted by or under the auspices of a federal government agency or nationally recognized federal research institute.

   2. (b) "Scientific evidence" does not include:

      1. (i) published peer-reviewed literature sponsored by:

         1. (A) a pharmaceutical manufacturing company; or
         2. (B) a medical device manufacturer; or
      2. (ii) a single study without other supportable studies.

8. (8)(a) "Urgent care claim" means a request for a health care service or course of treatment for which the time period for making non-urgent care request determination:

   1. (i) could seriously jeopardize the life or health of an insured or the ability of an insured to regain maximum function; or

      1. (ii) in the opinion of a physician with knowledge of the insured's medical condition, would subject an insured to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.

   2. (b)(i) Except as provided in Subsection (8)(a)(ii), an individual acting on behalf of a carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine to determine whether a request is an urgent care claim.

      1. (ii) If a physician with knowledge of an insured's medical condition determines that a request is an urgent care request within the meaning of Subsection (8)(a), the request shall be treated as an urgent care claim.

Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-629. Additional terms are defined as follows:

KEY: insurance

Date of Last Change: October 29, 2025

Notice of Continuation: March 31, 2022

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-203; 31A-4-116; 31A-22-629