28 Tex. Admin. Code § 11.2200 - Definitions

The following words and terms, when used in this subchapter, have the meaning indicated below unless the context clearly indicates otherwise:

(1) ADA--The American Dental Association.

(2) CDT--The current dental terminology manual developed and revised periodically by the ADA.

(3) ADA code/dental procedure description--Numerical codes and corresponding descriptions specified in the CDT to describe bona fide dental procedures.

(4) Comparable facility--The location where emergency dental services are rendered, including, but not limited to, the office of a licensed dentist, a dental clinic, hospital, freestanding emergency clinic, urgent care clinic, or other facility.

(5) Emergency dental services--Under a single service plan providing dental care services and benefits, emergency dental services are limited to procedures administered in a comparable facility, to evaluate and stabilize dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a prudent layperson possessing an average knowledge of dentistry to believe that immediate care is needed.

(6) Insurer--An insurance company, a group hospital service corporation operating under Insurance Code Chapter 842 (concerning Group Hospital Service Corporations), a fraternal benefit society operating under Insurance Code Chapter 885 (concerning Fraternal Benefit Societies), or a stipulated premium insurance company operating under Insurance Code Chapter 884 (concerning Stipulated Premium Insurance Companies).

(7) Point-of-service group disclosure statement--A written statement containing information about dental benefits that the HMO must provide to:

(A) an employer, an association, or other private group arrangement to whom the HMO must offer a dental point-of-service plan; and

(B) any prospective enrollees in a dental point-of-service plan, if the employer, association, or private group arrangement accepts the dental point-of-service plan.

(8) Point-of-service plan--A plan provided through a contractual arrangement under which indemnity benefits for the cost of dental care services other than emergency care or emergency dental care are provided by an insurer in conjunction with corresponding benefits arranged or provided by an HMO that provides dental benefits and under which an enrollee may choose to obtain benefits or services under either the indemnity plan or the HMO plan in compliance with Insurance Code § 843.112 (concerning Dental Point-of-Service Option).

(9) Qualified actuary--As defined in § 11.702 of this title (relating to Actuarial Certification).

Notes

28 Tex. Admin. Code § 11.2200

The provisions of this §11.2200 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective May 13, 1999, 24 TexReg 3525; amended to be effective February 24, 2005, 30 TexReg 854; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2263, eff. 8/1/2017