Sec. 4. (a) As used in this chapter, "medical claims review" means the determination of the reimbursement to be provided under the terms of an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for health care costs based on the appropriateness of health care services or the amount charged for a health care service delivered to an enrollee.
(b) The term does not include the prospective, concurrent, or retrospective utilization review of health care services.
(c) The term does not include the identification of alternative, optional medical care that:
(1) requires the approval of the enrollee or covered individual; and
(2) does not affect coverage or benefits if rejected by the enrollee or covered individual.
As added by P.L.128-1992, SEC.2. Amended by P.L.135-1994, SEC.1.