02-031 C.M.R. ch. 365, § 3 - Definitions

The following definitions apply for purposes of this rule:

1. "Carrier" has the same meaning as in 24-A M.R.S. §4301-A(3). Unless the context otherwise indicates, "carrier" also includes a participating self-insured health benefit plan.

2. "Control" has the same meaning as in 24-A M.R.S. §222(2)(B).

3. "Eligible patient" means:

A. an uninsured person who has received a bill for emergency services totaling $750 from one or more providers for a single visit; or

B. a person covered under a nonparticipating self-insured health plan who has received a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider, and did not knowingly elect to obtain the services from an out-of-network provider.

4. "Emergency services" has the same meaning as 24-A M.R.S. §4301-A(4-B).

5. "Enrollee" means a person covered by a carrier under a policy, certificate, or benefit plan.

6. "Geographic rating area" means an area designated by the Superintendent for health insurance rating purposes under 24-A M.R.S. §§2736-C(2) (C-1) & 2808-B(2)(C-1).

7. "Independent dispute resolution entity" or "IDRE" means an entity selected by the Superintendent pursuant to this rule to conduct the independent dispute resolution process.

8. "Material financial affiliation" means any financial interest of more than five percent of total annual revenue or total annual income of an IDRE or officer, director, or managers thereof; or arbitrator employed or engaged thereby to conduct any independent dispute review in the dispute resolution process. Revenue received from a carrier or physician by an IDRE to conduct a dispute resolution pursuant to this rule is not a material financial affiliation.

9. "Material personal affiliation" means any relationship as a spouse or domestic partner; as a child, parent, or sibling; as the child, parent, or sibling of a spouse or domestic partner; or as the spouse or domestic partner of a child, parent, or sibling.

10. "Material professional affiliation" means any physician-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent contractor arrangement that constitutes a material financial affiliation with any expert or any officer or director of the IDRE.

11. "Out-of-network provider" means a physician, hospital, or other provider that does not have a contract with the carrier to provide services to an enrollee.

12. "Participating self-insured health benefit plan" means a self-insured health benefit plan that has elected to participate in the IDR system pursuant to 24-A M.R.S. §4303-E(2) and subsection 6(7) of this rule.

13. "Surprise bill" has the same meaning as in 24-A M.R.S §4303-C(1).

Notes

02-031 C.M.R. ch. 365, § 3