Sections 432E-1 through 432E-2 designated as Part I by L
2011, c 230, §3.
§432E-1 Definitions. As used in this
chapter, unless the context otherwise requires:
"Adverse action" means an adverse
determination or a final adverse determination.
"Adverse determination" means a
determination by a health carrier or its designated utilization review
organization that an admission, availability of care, continued stay, or other
health care service that is a covered benefit has been reviewed and, based upon
the information provided, does not meet the health carrier's requirements for
medical necessity, appropriateness, health care setting, level of care, or
effectiveness, and the requested service or payment for the service is
therefore denied, reduced, or terminated.
"Ambulatory review" means a
utilization review of health care services performed or provided in an
"Appeal" means a request from an
enrollee to change a previous decision made by the health carrier.
"Appointed representative" means a
person who is expressly permitted by the enrollee or who has the power under
Hawaii law to make health care decisions on behalf of the enrollee, including:
(1) A person to whom an enrollee has given express
written consent to represent the enrollee in an external review;
(2) A person authorized by law to provide substituted
consent for an enrollee;
(3) A family member of the enrollee or the enrollee's
treating health care professional, only when the enrollee is unable to provide
(4) A court-appointed legal guardian;
(5) A person who has a durable power of attorney for
health care; or
(6) A person who is designated in a written advance
provided that an appointed representative shall
include an "authorized representative" as used in the federal Patient
Protection and Affordable Care Act.
"Best evidence" means evidence based
(1) Randomized clinical trials;
(2) If randomized clinical trials are not available,
cohort studies or case-control studies;
(3) If the trials in paragraphs (1) and (2) are not
available, case-series; or
(4) If the sources of information in paragraphs (1),
(2), and (3) are not available, expert opinion.
"Case-control study" means a
prospective evaluation of two groups of patients with different outcomes to
determine which specific interventions the patients received.
"Case management" means a coordinated
set of activities conducted for individual patient management of serious,
complicated, protracted, or other health conditions.
"Case-series" means an evaluation of
patients with a particular outcome, without the use of a control group.
"Certification" means a determination
by a health carrier or its designated utilization review organization that an
admission, availability of care, continued stay, or other health care service
has been reviewed and, based on the information provided, satisfies the health
carrier's requirements for medical necessity, appropriateness, health care
setting, level of care, and effectiveness.
"Clinical review criteria" means the
written screening procedures, decision abstracts, clinical protocols, and
practice guidelines used by a health carrier to determine the necessity and
appropriateness of health care services.
"Cohort study" means a prospective
evaluation of two groups of patients with only one group of patients receiving
a specific intervention.
"Commissioner" means the insurance
"Complaint" means an expression of
dissatisfaction, either oral or written.
"Concurrent review" means a
utilization review conducted during a patient's hospital stay or course of
"Covered benefits" or
"benefits" means those health care services to which an enrollee is
entitled under the terms of a health benefit plan.
"Discharge planning" means the formal
process for determining, prior to discharge from a facility, the coordination
and management of the care that an enrollee receives following discharge from a
"Disclose" means to release,
transfer, or otherwise divulge protected health information to any person other
than the individual who is the subject of the protected health information.
"Emergency services" means services
provided to an enrollee when the enrollee has symptoms of sufficient severity,
including severe pain, such that 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 organ or part, or death.
"Enrollee" means a person who enters
into a contractual relationship under or who is provided with health care
services or benefits through a health benefit plan.
"Evidence-based standard" means the
conscientious, explicit, and judicious use of the current best evidence based
on the overall systematic review of the research in making decisions about the
care of individual patients.
"Expert opinion" means a belief or
interpretation by specialists with experience in a specific area about the
scientific evidence pertaining to a particular service, intervention, or
"External review" means a review of
an adverse determination (including a final adverse determination) conducted by
an independent review organization pursuant to this chapter.
"Facility" means an institution
providing health care services or a health care setting, including but not
limited to, hospitals and other licensed inpatient centers, ambulatory surgical
or treatment centers, skilled nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and rehabilitation and other
therapeutic health settings.
"Final adverse determination" means
an adverse determination involving a covered benefit that has been upheld by a
health carrier or its designated utilization review organization at the
completion of the health carrier's internal grievance process procedures, or an
adverse determination with respect to which the internal appeals process is
deemed to have been exhausted under section 432E-33(b).
"Health benefit plan" means a policy,
contract, certificate or agreement offered or issued by a health carrier to
provide, deliver, arrange for, pay or reimburse any of the costs of health care
"Health care professional" means an
individual licensed, accredited, or certified to provide or perform specified
health care services in the ordinary course of business or practice of a
profession consistent with state law.
"Health care provider" or
"provider" means a health care professional.
"Health care services" means services
for the diagnosis, prevention, treatment, cure, or relief of a health
condition, illness, injury, or disease.
"Health carrier" means an entity
subject to the insurance laws and rules of this State, or subject to the jurisdiction
of the commissioner, that contracts or offers to contract to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health care services,
including a sickness and accident insurance company, a health maintenance
organization, a mutual benefit society, a nonprofit hospital and health service
corporation, or any other entity providing a plan of health insurance, health
benefits or health care services.
"Health maintenance organization"
means a health maintenance organization as defined in section 432D-1.
"Independent review organization"
means an independent entity that conducts independent external reviews of
adverse determinations and final adverse determinations.
"Internal review" means the review
under section 432E-5 of an enrollee's complaint by a health carrier.
"Managed care plan" means any plan,
policy, contract, certificate, or agreement, regardless of form, offered or
administered by any person or entity, including but not limited to an insurer
governed by chapter 431, a mutual benefit society governed by chapter 432, a
health maintenance organization governed by chapter 432D, a preferred provider
organization, a point of service organization, a health insurance issuer, a
fiscal intermediary, a payor, a prepaid health care plan, and any other mixed
model, that provides for the financing or delivery of health care services or
benefits to enrollees through:
(1) Arrangements with selected providers or provider
networks to furnish health care services or benefits; and
(2) Financial incentives for enrollees to use
participating providers and procedures provided by a plan;
provided that for the purposes of this chapter, an
employee benefit plan shall not be deemed a managed care plan with respect to
any provision of this chapter or to any requirement or rule imposed or
permitted by this chapter that is superseded or preempted by federal law.
"Medical director" means the person
who is authorized under a health carrier and who makes decisions for the health
carrier denying or allowing payment for medical treatments, services, or
supplies based on medical necessity or other appropriate medical or health plan
"Medical necessity" means a health
intervention that meets the criteria enumerated in section 432E-1.4.
"Medical or scientific evidence"
means evidence found in the following sources:
(1) Peer-reviewed scientific studies published in or
accepted for publication by medical journals that meet nationally-recognized
requirements for scientific manuscripts and that submit most of their published
articles for review by experts, who are not part of the editorial staff;
(2) Peer-reviewed medical literature, including
literature relating to therapies reviewed and approved by a qualified
institutional review board, biomedical compendia, and other medical literature
that meet the criteria of the National Institutes of Health's National Library
of Medicine for indexing in Index Medicus and Elsevier Science Ltd. for
indexing in Excerpta Medicas;
(3) Medical journals recognized by the United States
Secretary of Health and Human Services under section 1861(t)(2) of the federal
Social Security Act;
(4) The following standard reference compendia:
(A) The American Hospital Formulary
(B) Drug Facts and Comparisons;
(C) The American Dental Association Accepted
Dental Therapeutics; and
(D) The United States Pharmacopeia Drug
(5) Findings, studies, or research conducted by or
under the auspices of federal government agencies and nationally-recognized
federal research institutes, including:
(A) The federal Agency for Healthcare Research
(B) The National Institutes of Health;
(C) The National Cancer Institute;
(D) The National Academy of Sciences;
(E) The Centers for Medicare and Medicaid
(F) The federal Food and Drug Administration;
(G) Any national board recognized by the
National Institutes of Health for the purpose of evaluating the medical value
of health care services; or
(6) Any other medical or scientific evidence that is
comparable to the sources listed in paragraphs (1) through (5).
"Participating provider" means a
licensed or certified provider of health care services or benefits, including
mental health services and health care supplies, who has entered into an
agreement with a health carrier to provide those services or supplies to
"Prospective review" means
utilization review conducted prior to an admission or a course of treatment.
"Protected health information" means
health information as defined in the federal Health Insurance Portability and
Accountability Act and related federal rules.
"Randomized clinical trial" means a
controlled, prospective study of patients who have been randomized into an
experimental group and a control group at the beginning of the study with only
the experimental group of patients receiving a specific intervention, which
includes study of the groups for variables and anticipated outcomes over time.
"Retrospective review" means a review
of medical necessity conducted after services that have been provided to a
patient, but does not include the review of a claim that is limited to an
evaluation of reimbursement levels, veracity of documentation, accuracy of
coding, or adjudication for payment.
"Reviewer" means an independent
reviewer with clinical expertise either employed by or contracted by an
independent review organization to perform external reviews.
"Second opinion" means an opportunity
or requirement to obtain a clinical evaluation by a provider other than the one
originally making a recommendation for a proposed health care service to assess
the clinical necessity and appropriateness of the initial proposed health care
"Specifically excluded" means that
the coverage provisions of the health care plan, when read together, clearly
and specifically exclude coverage for a health care service.
"Utilization review" means a set of
formal techniques designed to monitor the use of, or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of, health care services,
procedures, or settings. Techniques may include ambulatory review, prospective
review, second opinion, certification, concurrent review, case management,
discharge planning, or retrospective review.
"Utilization review organization"
means an entity that conducts utilization review other than a health carrier
performing a review for its own health benefit plans. [L 1998, c 178, pt of §2;
am L 1999, c 273, §2; am L 2000, c 250, §3; am L 2011, c 230, §6; am L 2015, c
As chapter 432D does not cover the field of managed care
regulation and because this section, §432D-2, and article 431:10A can be
read together and there is no explicit language or policy reason not to give
each statute effect, chapter 432D does not repeal chapter 432E by implication.
126 H. 326, 271 P.3d 621 (2012).