As used in this chapter, the term:

(1) "Certificate" means a certificate of registration granted by the Commissioner to a private review agent.

(2) "Claim administrator" means any entity that reviews and determines whether to pay claims to enrollees of health care providers on behalf of the health benefit plan. Such payment determinations are made on the basis of contract provisions including medical necessity and other factors. Claim administrators may be payors or their designated review organization, self-insured employers, management firms, third-party administrators, or other private contractors.

(3) "Commissioner" means the Commissioner of Insurance.

(4) "Enrollee" means the individual who has elected to contract for or participate in a health benefit plan for himself or himself and his eligible dependents.

(5) "Health benefit plan" means a plan of benefits that defines the coverage provisions for health care for enrollees offered or provided by any organization, public or private.

(6) "Health care advisor" means a health care provider licensed in a state representing the claim administrator or private review agent who provides advice on issues of medical necessity or other patient care issues.

(7) "Health care provider" means any person, corporation, facility, or institution licensed by this state or any other state to provide or otherwise lawfully providing health care services, including but not limited to a doctor of medicine, doctor of osteopathy, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist, psychologist, occupational therapist, professional counselor, pharmacist, chiropractor, marriage and family therapist, or social worker.

(8) "Payor" means any insurer, as defined in this title, or any preferred provider organization, health maintenance organization, self-insurance plan, or other person or entity which provides, offers to provide, or administers hospital, outpatient, medical, or other health care benefits to persons treated by a health care provider in this state pursuant to any policy, plan, or contract of accident and sickness insurance as defined in Code Section 33-7-2.

(9) "Private review agent" means any person or entity which performs utilization review for:

(A) An employer with employees who are treated by a health care provider in this state;

(B) A payor; or

(C) A claim administrator.

(10) "Reasonable target review period" means the assignment of a proposed number of days for review for the proposed health care services based upon reasonable length of stay standards such as the Professional Activities Study of the Commission on the Professional and Hospital Activities or other Georgia state-specific length of stay data.

(11) "Utilization review" means a system for reviewing the appropriate and efficient allocation or charges of hospital, outpatient, medical, or other health care services given or proposed to be given to a patient or group of patients for the purpose of advising the claim administrator who determines whether such services or the charges therefor should be covered, provided, or reimbursed by a payor according to the benefits plan. Utilization review shall not include the review or adjustment of claims or the payment of benefits arising under liability, workers' compensation, or malpractice insurance policies as defined in Code Section 33-7-3.

(12) "Utilization review plan" means a reasonable description of the standards, criteria, policies, procedures, reasonable target review periods, and reconsideration and appeal mechanisms governing utilization review activities performed by a private review agent.