US Laws, Codes, Statutes & Cases

      Sec. 38a-226. Definitions. For purposes of sections 38a-226 to 38a-226d, inclusive:

      (1) "Utilization review" means the prospective or concurrent assessment of the necessity and appropriateness of the allocation of health care resources and services given or proposed to be given to an individual within this state. Utilization review shall not include elective requests for clarification of coverage.

      (2) "Utilization review company" means any company, organization or other entity performing utilization review, except:

      (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) Any agency of the state of Connecticut; or

      (D) A hospital's internal quality assurance program except if associated with a health care financing mechanism.

      (3) "Commissioner" means the Insurance Commissioner.

      (4) "Enrollee" means an individual who has contracted for or who participates in coverage under an insurance policy, a health care center contract, an employee welfare benefits plan, a hospital or medical services plan contract or any other benefit program providing payment, reimbursement or indemnification for health care costs for an individual or his eligible dependents.

      (5) "Provider of record" or "provider" means the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for the care, treatment and services rendered to an individual.

      (P.A. 91-305, S. 1; P.A. 97-99, S. 15, 32.)

      History: P.A. 97-99 made no changes.