External Review Definitions
What is meant by "explicitly excluded?"
Your health insurance evidence of coverage tells you what is covered under your plan. It will also have a section of exclusions. For example, some plans specifically exclude acupuncture; others might exclude coverage for dental procedures. Because these exclusions apply to all such services for all members, a request for a non-covered service is not eligible for external review.
Services that are covered under certain circumstances or when certain criteria are met are eligible for external review. For example, a health plan denies a procedure because it considers it to be cosmetic, but the patient's physician states that the procedure addresses a functional deformity. Such a denial would be considered an adverse determination and therefore eligible for external review.
What is a "final adverse determination?"
An adverse determination is a decision by the health plan to deny, reduce, modify or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness. A final adverse determination is an adverse determination made after an insured has exhausted all remedies available through a health plan's formal internal grievance process.
What is a “fully-insured health plan?”
A fully-insured health plan is a health insurance plan purchased by an employer from an insurance company. Fully-insured plans are usually regulated by state government.
Some employers have self-funded or self-insured health plans. Under a self-insured or self-funded plan, your employer pays the costs for its employees' health care directly instead of paying premiums to buy health insurance. Some self-insured employers hire insurance companies to process the paperwork, so it is not always easy to tell if you are in a self-funded plan. Self-insured plans are usually regulated by the federal government. Ask your employer if you are not sure if your health plan is fully-insured or self-insured.
What is “medical necessity?”
Medical necessity means health care services that are consistent with the generally accepted principles of professional medical practice as determined by whether the service:
1. Is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual;
2. Is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
3. For services and interventions not in widespread use, is based on scientific evidence.