A. "Administrator" means any person, other
than a carrier, that administers a preferred provider arrangement.
B. "Copy" of any document to be filed with
the Superintendent means a draft copy if a final copy is not reasonably
available at the time of filing.
"Emergency services" means those health care services that are provided in an
emergency facility or setting after the onset of an illness or medical
condition that manifests itself by symptoms of sufficient severity that the
absence of immediate medical attention could reasonably be expected by the
prudent lay person, who possesses an average knowledge of health and medicine,
to result in:
(1) Serious jeopardy to the
enrollee's physical and/or mental health;
(2) Serious impairment to bodily functions;
(3) Serious dysfunction of any
bodily organ or part.
"Health care services" means health care services or products rendered or sold
by a provider within the scope of the provider's legal authorization.
E. "Health Maintenance Organization" means
an organization of the kind defined at
"Medically necessary health care" means
health care services or products provided to an enrollee for the purpose of
preventing, diagnosing, or treating an illness, injury, or disease or the
symptoms of an illness, injury, or disease in a manner that is:
(1) Consistent with generally accepted
standards of medical practice;
Clinically appropriate in terms of type, frequency, extent, site, and
(3) Demonstrated through
scientific evidence to be effective in improving health outcomes;
(4) Representative of "best practices" in the
medical profession; and
primarily for the convenience of the enrollee or physician or other health
"Preferred provider arrangement" means a contract, agreement, or arrangement
between a carrier or administrator and a provider in which the provider agrees
to provide services to a health plan enrollee whose plan benefits include
incentives for the enrollee to use the services of that provider.
H. "Special condition" means a condition or
disease that is life-threatening, degenerative, or disabling and requires
specialized medical care over a prolonged period of time.