District of Columbia Code Division V. Local Business Affairs § 31-3875.01. Definitions.

(1) “Adverse determination” means a decision by a utilization review entity that the health care services furnished or proposed to be furnished to an enrollee is denied, reduced, or terminated as being not medically necessary or experimental or investigational.

(2) “Approval” means a determination by a utilization review entity that a covered health care service has been reviewed and, based on the information provided, satisfies the utilization review entity's requirements for medical necessity and medical appropriateness.

(3) “Emergency health care service” means a health care service that is provided in an emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to place the patient's health in serious jeopardy or to cause serious impairment to bodily function or serious dysfunction of any bodily organ or part.

(4) “Enrollee” means an individual eligible to receive health care benefits by a health insurer pursuant to a health plan or other health insurance coverage.

(5) “Long-term services and supports” means institutional and home and community-based services provided under the District's Medicaid State Plan or any corresponding waiver thereof, including long-term nursing facility care, intermediate care facility services, State Plan home health and personal care aide services, services covered under the Program for All-Inclusive Care for the Elderly, and home and community-based services authorized under section 1915(c) and (i) of the Social Security Act, approved August 13, 1981 (95 Stat. 809; 42 U.S.C. 1396n(c) and (i)), and section 1115 of the Social Security Act, approved July 25, 1962 (76 Stat. 192; 42 U.S.C. § 1315).

(6) “Medication assisted treatment” means the use of medications to provide a comprehensive approach to the treatment of substance use disorders.

(7) “Prior authorization” means the process by which a utilization review entity determines the medical necessity or medical appropriateness of covered health care services prior to the rendering of such services, including any notification that an enrollee or health care provider is required to provide to the health insurer or utilization review entity prior to the provision of a health care service.

(8) “Representative” means the enrollee's legally authorized representative.

(9) “Urgent health care service” means:

(10) “Utilization review entity” means an individual or entity that performs prior authorization review for: