A. Board means the State Board of Health.

B. Certificate means a certificate of registration granted by the State Board of Health to a private review agent.

C. Director means the Director of the Arkansas Department of Health or his/her designee.

D. Hospital means any facility established for the purpose of providing inpatient diagnostic care and treatment for two or more unrelated persons for more than 24 hours may not be conducted or maintained in this State without being licensed.

E. Private Review Agent means a non-hospital affiliated entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of an Arkansas business entity or third party that provides or administers hospital and medical benefits to citizens of this State including a health maintenance organization or entity offering health insurance policies, contracts or benefits in this state including a health insurer, non-profit health service plan, health insurance service organization, or preferred provider organization.

F. 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. More specifically, utilization review refers to a preservice determination of the medical necessity or appropriateness of services to be rendered in a hospital setting either on an inpatient or outpatient basis, when such determination results in approval or denial of payment for the services. It includes prospective, concurrent or retrospective reviews.

G. Utilization Review Plan means a description of the standards governing utilization review activities performed by a private review agent.

H. Utilization Review Representative means the person(s) in a physician office or hospital designated by the physician or hospital to provide the necessary information to complete the review process.

I. Consulting Physician means a Medical Doctor, Doctor of Osteopathy, Dentist or Chiropractor who possess the degree of skill ordinarily possessed and used by members of his or her profession in good standing engaged in the same type of practice and specialty in the locality where the service under review occurred or in a similar locality.

J. Certified Private Review Agent means a private review agent who meets all the criteria for certification as set forth in these Rules and Regulations, has paid all current fees, and has been assigned a certification number.