28 Tex. Admin. Code § 21.3402 - Definitions
The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:
(1) Claims incurred--Paid
claims plus amounts held in reserve for claims that have been incurred but have
not yet been paid.
(2) Direct
premium--The amount of health premiums earned for comprehensive health coverage
as reported on an issuer's submission to the NAIC for the year for which it is
reporting data.
(3) Health benefit
plan--A health benefit plan regulated under Insurance Code Title 8 (concerning
Health Insurance and Other Health Coverages), Subtitles A (concerning Health
Coverage in General), B (concerning Group Health Coverage), C (concerning
Managed Care), D (concerning Provider Plans), and G (concerning Health Coverage
Availability).
(4) Mandated
benefit--A health benefit listed in §
21.3406(b) of
this title (relating to Mandates for Which Data Must Be Reported) that must be
included in a health benefit plan.
(5) Mandated offer--An offer of coverage
listed in §
21.3406(c) of
this title (relating to Mandates for Which Data Must Be Reported) that must be
offered and made available to the holder or sponsor of an individual or group
health benefit plan.
(6) Medical
billing codes--Standard code sets used to bill for specific medical services,
including the Healthcare Common Procedure Coding System (HCPCS) and
diagnosis-related group (DRG) system established by the Centers for Medicare
and Medicaid Services (CMS), the Current Procedural Terminology (CPT) code set
maintained by the American Medical Association, and the International
Classification of Diseases (ICD) code sets developed by the World Health
Organization. TDI's list of suggested mandated benefit codes is shown on its
website, www.tdi.texas.gov.
(7)
Member months--The cumulative number of months that all enrollees were covered
during the reporting year.
(8)
Reporting entity--A health benefit plan issuer or a third-party administrator
that performs claims payment services for a health benefit plan issuer to which
this subchapter applies.
(9)
Reporting year--A one-year period, beginning each January 1 and ending the
following December 31, for which health benefit plan issuers must collect the
data required by §
21.3407 of this title (relating to
Reporting of Required Information).
(10) Third-party administrator--An
administrator holding a certificate of authority under Insurance Code Chapter
4151 (concerning Third-Party Administrators).
Notes
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