Alabama § 27-48-1 - Definitions.

§ 27-48-1. Definitions.

As used in this chapter, the following terms shall have the following meanings:

(1) HEALTH BENEFIT PLAN. A health insurance policy that covers hospital, medical, or surgical expenses, health maintenance organizations, preferred provider organizations, medical service organizations, physician-hospital organizations, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes health care services to patients, insureds, or beneficiaries in this state. For the purpose of this chapter, a health benefit plan located or domiciled outside of the State of Alabama is deemed to be subject to the provisions of this chapter if it receives, processes, adjudicates, pays, or denies claims for health care services submitted by or on behalf of the State of Alabama or who receive health care services in the State of Alabama. The term includes, but is not limited to, entities created pursuant to Article 6 of Chapter 4 of Title 10.

(2) MEDICALLY NECESSARY. A medical or surgical service, including inpatient hospital care, is medically necessary when in the opinion of the attending physician or the attending certified nurse midwife practicing in collaboration with an obstetrician-gynecologist, the patient’s health would be adversely affected if the service is withheld or discontinued. Medically necessary postpartum care for a mother and a newly born child shall be consistent with the most recent version of the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.