RSA 420-J:3 Definitions.

In this chapter:
I. "Adverse determination" means a determination by a health carrier or its designee utilization review entity that an admission, availability of care, continued stay or other health care service 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 is therefore denied, reduced, or terminated.
II. "Ambulatory review" means utilization review of health care services performed or provided in an outpatient setting.
III. "Appeals procedure" means a formal process whereby a covered person, a representative of a covered person, attending physician, facility or health care provider can