19 Miss. Code. R. 3-14.03 - Definitions
For purposes of this Regulation:
A. "Commissioner" means the Commissioner of
Insurance.
B. "Covered benefits" or
"benefits" means those health care services to which a covered person is
entitled under the terms of a health benefit plan.
C. "Covered person" means a policyholder,
subscriber, enrollee. or other individual participating in a health benefit
plan.
D. "Emergency medical
condition" means the sudden and, at the time, unexpected onset of a health
condition that requires immediate medical attention, where failure to provide
medical attention would result in serious impairment to bodily functions or
serious dysfunction of a bodily organ or part, or would place the person's
health in serious jeopardy.
E.
"Emergency services" means health care items and services furnished or required
to evaluate and treat an emergency medical condition.
F. "Facility" means an institution providing
health care services or a health care setting, including, but not limited to.
hospitals and other licensed inpatient centers, ambulatory surgical or
treatment centers, skilled nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and rehabilitation and other
therapeutic health settings.
G.
"Health benefit plan" means a policy, contract, certificate or agreement
entered into, offered or issued by a health carrier to provide, deliver,
arrange for, pay for or reimburse any of the costs of health care
services.
H. "Health care
professional" means a physician or other health care practitioner licensed,
accredited, or certified to perform specified health services consistent with
state law.
I. "Health care
provider" or "provider" means a health care professional or a
facility.
J. "Health care services"
means services for the diagnosis, prevention, treatment, cure, or relief of a
health condition, illness, injury, or disease.
K. "Health carrier" means an entity subject
to the insurance laws and regulations of this state. or subject to the
jurisdiction of the Commissioner, that contracts or offers to contract, or
enters into an agreement to provide, deliver, arrange for. pay for. or
reimburse any of the costs of health care services, including a sickness and
accident insurance company, a third party administrator, a health maintenance
organization, a nonprofit hospital, health service corporation, or any other
entity providing a plan of health insurance, health benefits, or health
services.
L. "Intermediary" means a
person authorized to negotiate and execute provider contracts with health
carriers on behalf of health care providers or on behalf of a
network.
M. "Managed care plan"
means a plan as defined by Miss. Code Ann.
§
83-41-403(b).
N. "Network" means
the group of participating providers providing services to a managed care plan
and who have entered into a contract of reimbursement for benefits with a
health carrier.
O. "Participating
provider" means a provider as defined by Miss. Code Ann.
§
83-41-403(e).
P. "Person" means an
individual, a corporation, a partnership, an association, a joint venture, a
joint stock company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
Q. "Primary care professional" means a
participating health care professional designated by the health carrier to
supervise, coordinate, or provide initial care or continuing care to a covered
person, and who may be required by the health carrier to initiate a referral
for specialty care and maintain supervision of health care services rendered to
the covered person.
Notes
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