28 Tex. Admin. Code § 21.4503 - Definitions

The following words and terms when used in this subchapter have the following meanings unless the context clearly indicates otherwise:

(1) Allowed amount--The amount that the applicable health benefit plan issuer allows as payment for a health care service or group of services, including amounts for which a patient is responsible due to deductibles, copayments, or coinsurance.

(2) Ambulatory surgical center--A facility licensed under Health and Safety Code Chapter 243.

(3) Applicable health benefit plan--A group health benefit plan as specified in Insurance Code § 38.352 and § 38.353, which is a preferred provider benefit plan as defined by Insurance Code § 1301.001, including an exclusive provider benefit plan consistent with Insurance Code § 1301.0042, or an evidence of coverage for a health care plan that provides basic health care services as defined by Insurance Code § 843.002, or a state employee health plan under Insurance Code Chapters 1551, 1575, 1579, and 1601. The term does not include an HMO plan providing routine dental or vision services as a single health care service plan or a preferred provider benefit plan providing routine vision services as a single health care service plan.

(4) Billed amount--The amount charged for health care services on a claim submitted by a provider.

(5) Facility claims--Any claim for health care services provided by a facility as defined in § 3.3702 of this title.

(6) Freestanding emergency medical care facility--A freestanding emergency medical care facility required to be licensed under Health and Safety Code Chapter 254.

(7) Geographic region--A three-digit ZIP code representing the collection of ZIP codes that share the same first three digits. For purposes of data submitted under this subchapter, a geographic region must be located in Texas, in full or in part.

(8) Imaging claims--Claims for radiological services furnished in a provider office, outpatient hospital, or other outpatient environment.

(9) Inpatient procedure claims--Claims for health care services furnished in a hospital, as defined by Insurance Code § 1301.001, to a patient who is formally admitted.

(10) In-network claims--Claims filed with an applicable health benefit plan for health care treatment, services, or supplies furnished by a provider contracted as an in-network or preferred provider under the plan.

(11) 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.

(12) Out-of-network claims--Claims filed with an applicable health benefit plan for health care treatment, services, or supplies furnished by a provider that is not an in-network provider or preferred provider under the plan. Claims paid on an out-of-network basis are considered out-of-network regardless of whether the provider is reimbursed based on an agreed on rate.

(13) Outpatient facility procedure claims--Claims for health care services furnished in an ambulatory surgical center or a hospital, as defined by Insurance Code § 1301.001, to a patient who is not formally admitted.

(14) Place-of-service code--A health care claim code where "place of service" refers to the type of entity where services were rendered, as specified by a two-digit place-of-service code on a professional health care claim consistent with the ASC X12N standard for electronic transactions. Place-of-service codes are maintained by CMS.

(15) Primary plan--As defined in paragraph (17) of this section.

(16) Professional claims--Any claim for health care services provided by a physician or provider that is not an institutional provider, as defined in Insurance Code § 1301.001.

(17) Provider--Any physician, practitioner, institutional provider, or other person or organization that furnishes health care services and is licensed or otherwise authorized to practice in this state.

(18) Reporting period--The 12-month interval of time for which a plan or applicable health benefit plan issuer must submit data each year, beginning each January 1 and ending the following December 31.

(19) TDI--Texas Department of Insurance.

Notes

28 Tex. Admin. Code § 21.4503

The provisions of this §21.4503 adopted to be effective January 9, 2011, 35 TexReg 11868; Amended by Texas Register, Volume 41, Number 23, June 3, 2016, TexReg 4027, eff. 6/6/2016