(a) “Utilization review” means a system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients as to necessity for the purpose of determining whether such service should be covered or provided by an insurer, plan or other entity.
(b) “Private review agent” means a nonhospital-affiliated person or entity performing utilization review on behalf of:
(i) An employer or employees in the State of Mississippi; or
(ii) A third party that provides or administers hospital and medical benefits to citizens of this state, including: a health maintenance organization issued a certificate of authority under and by virtue of the laws of the State of Mississippi; or a health insurer, nonprofit health service plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state.
(c) “Utilization review plan” means a description of the utilization review procedures of a private review agent.
(d) “Department” means the Mississippi State Department of Health.
(e) “Certificate” means a certificate of registration granted by the Mississippi State Department of Health to a private review agent.
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