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Title 26 Insurance Code

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Change 1

What to do with it
As published

26-40-102. Definitions.

(a) As used in this chapter: (i) "Health care provider" means any physician, hospital or other person licensed or otherwise authorized in this or another state to furnish to any individual medical or dental care, vision care or hospitalization incident to the furnishing of that care or hospitalization for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability; (ii) "Usual, customary and reasonable basis" means the method by which an insurer determines the amount to be paid on a claim for disability benefits by comparing the amount of the claim to amounts charged by other health care providers for the same or similar medical services or procedures; (iii) "Medical necessity," means: (A) A medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that: (I) Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury; (II) Provides for the diagnosis, direct care and treatment of the patient's condition, illness, disease or injury; (III) Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and (IV) Is not primarily for the convenience of the patient, physician or other health care provider. (B) A medical service, procedure or supply shall not be excluded from being a medical necessity under this section solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by: (I) 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 Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); or (II) Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act.

Your change, as a redline

26-40-102. Definitions.

(a) As used in this chapter: (i) "Health care provider" means any physician, hospital or other person licensed or otherwise authorized in this or another state to furnish to any individual medical or dental care, vision care or hospitalization incident to the furnishing of that care or hospitalization for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability; (ii) "Usual, customary and reasonable basis" means the method by which an insurer determines the amount to be paid on a claim for disability benefits by comparing the amount of the claim to amounts charged by other health care providers for the same or similar medical services or procedures; (iii) "Medical necessity," means: (A) A medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that: (I) Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury; (II) Provides for the diagnosis, direct care and treatment of the patient's condition, illness, disease or injury; (III) Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and (IV) Is not primarily for the convenience of the patient, physician or other health care provider. (B) A medical service, procedure or supply shall not be excluded from being a medical necessity under this section solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by: (I) 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 Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); or (II) Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act.

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