Effective - 28 Aug 2019, 2 histories
374.500. Definitions. — As used in sections 374.500 to 374.515, the following terms mean:
(1) "Certificate", a certificate of registration granted by the department of commerce and insurance to a utilization review agent;
(2) "Director", the director of the department of commerce and insurance;
(3) "Enrollee", an individual who has contracted for or who participates in coverage under a health insurance policy, an employee welfare benefit plan, a health services corporation plan or any other benefit program providing payment, reimbursement or indemnification for health care costs for himself or eligible dependents or both himself and eligible dependents. The term "enrollee" shall not include an individual who has health care coverage pursuant to a liability insurance policy, workers' compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy;
(4) "Provider of record", the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for the care, treatment and services rendered to an enrollee;
(5) "Utilization review", 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, prior authorization review, second opinion, certification, concurrent review, case management, discharge planning or retrospective review. Utilization review shall not include elective requests for clarification of coverage;
(6) "Utilization review agent", any person or entity performing utilization review, except:
(a) An agency of the federal government;
(b) An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government; or
(c) Any individual person employed or used by a utilization review agent for the purpose of performing utilization review services, including, but not limited to, individual nurses and physicians, unless such individuals are providing utilization review services to the applicable benefit plan, pursuant to a direct contractual relationship with the benefit plan;
(d) An employee health benefit plan that is self-insured and qualified pursuant to the federal Employee Retirement Income Security Act of 1974, as amended;
(e) A property-casualty insurer or an employee or agent working on behalf of a property-casualty insurer;
(f) A health carrier, as defined in section 376.1350, that is performing a review of its own health plan;
(7) "Utilization review plan", a summary of the utilization review procedures of a utilization review agent.
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(L. 1991 S.B. 352 § 1, A.L. 1993 H.B. 709, A.L. 1997 H.B. 335, A.L. 2019 S.B. 514)
Structure Missouri Revised Statutes
Title XXIV - Business and Financial Institutions
Chapter 374 - Department of Commerce and Insurance
Section 374.005 - Department created, duties — definitions.
Section 374.007 - Statutory reference changes authorized.
Section 374.010 - Department — general powers.
Section 374.020 - Director — qualifications — appointment.
Section 374.030 - Director — oath — bond.
Section 374.040 - Director — duties — administrative hearing commission law not applicable.
Section 374.045 - Director authorized to make rules and regulations, procedure, this chapter.
Section 374.047 - Willful violation of state law, order — notice.
Section 374.050 - Seal of office — effect.
Section 374.051 - Refusal of license and nonrenewal, applicant may appeal, procedure.
Section 374.055 - Grievance procedure.
Section 374.056 - Rulemaking authority, delivery methods.
Section 374.057 - Filing of records and signatures authorized when in compliance with federal law.
Section 374.060 - Office location and hours.
Section 374.070 - Office and records, public — copies — records disposed of or destroyed, when.
Section 374.071 - Insurance records exempt from public disclosure — release permitted, when.
Section 374.075 - Divisions, director may establish.
Section 374.080 - Deputy director, appointment, powers — governor to appoint, when.
Section 374.085 - Division of consumer affairs, duties — legal adviser may assist.
Section 374.100 - Actuary — duties — fees.
Section 374.110 - Examiner — duties — assistants — fees.
Section 374.130 - Chief clerk, duties and powers.
Section 374.170 - Forms furnished companies.
Section 374.180 - Director to prepare report — publication — special reports.
Section 374.182 - Organization plan to be submitted — contents.
Section 374.185 - Uniformity of regulation, director to cooperate.
Section 374.190 - Investigation of companies.
Section 374.202 - Purpose of law — definitions.
Section 374.210 - False testimony — refusal to furnish information — penalties.
Section 374.215 - Failure to timely file report or statement, penalty.
Section 374.216 - False financial statements, filing of — penalty.
Section 374.217 - Covenant not to sue officers of insurer, prohibited — no force and effect.
Section 374.220 - Expenses, how paid.
Section 374.230 - Fees — paid to director.
Section 374.240 - Suit to recover fees — penalties.
Section 374.250 - Accounts of director.
Section 374.270 - Department may elect workers' compensation coverage — coverage, how provided.
Section 374.280 - Civil penalty or forfeiture ordered when, how enforced.
Section 374.284 - Health insurance advisory committee established, members, duties.
Section 374.285 - Expungement of certain disciplinary action records.
Section 374.300 - Financial institution defined.
Section 374.310 - Refusal to grant or renew insurance license, when.
Section 374.350 - Short title.
Section 374.351 - Intent of compact.
Section 374.400 - Definitions.
Section 374.405 - Reports of premiums and loss data required, when — director may review.
Section 374.415 - Product liability insurance reports required — when — contents.
Section 374.420 - Insurers not liable because of compliance.
Section 374.425 - Time for compliance may be waived or extended.
Section 374.450 - Definitions.
Section 374.455 - Premium and loss data, annual report — available to public.
Section 374.500 - Definitions.
Section 374.503 - Certificate required for utilization review agents, exceptions.
Section 374.505 - Application for certificate, content, form, fee.
Section 374.507 - Information may be required by department of commerce and insurance.
Section 374.510 - Minimum requirements for utilization review agents.
Section 374.515 - Rules and regulations authorized.
Section 374.695 - Citation of law.
Section 374.700 - Definitions.
Section 374.702 - License required, restrictions on practice.
Section 374.705 - Department, powers and duties — fees, how determined.
Section 374.710 - License required for bail bond agents, application, qualifications — exceptions.
Section 374.717 - Prohibited acts.
Section 374.720 - Examination, form, content — reexamination fee.
Section 374.730 - License, biannual renewal, fee.
Section 374.740 - Nonresident license requirements.
Section 374.750 - Refusal to issue or renew license — applicant's right to hearing.
Section 374.760 - Unsatisfied judgments, affidavit filed monthly, form — content.
Section 374.764 - Alleged violations and complaints, procedure.
Section 374.775 - Bonds of one thousand dollars or less — fee — additional fee — prohibited.
Section 374.783 - Surety recovery agents, license required — director to license, powers.
Section 374.785 - Apprehension of defendant, permitted where.
Section 374.786 - Renewal, procedure.
Section 374.787 - Complaint procedure.
Section 374.788 - Apprehension standards for breach of surety agreement or absconding.