28 Tex. Admin. Code § 21.5003 - Definitions
The following words and terms have the following meanings when used in this subchapter unless the context clearly indicates otherwise.
(1) Administrator--Has the
meaning assigned by Insurance Code §
1467.001, concerning
Definitions. The term also includes an administrator of a nonprofit
agricultural organization under Insurance Code Chapter 1682, concerning Health
Benefits Provided by Certain Nonprofit Agricultural Organizations, and an
administrator of a self-insured or self-funded ERISA plan under Insurance Code
Chapter 1275, concerning Balance Billing Prohibitions and Out-of-Network Claim
Dispute Resolution for Certain Plans, offering a health benefit plan.
(2) Arbitration--Has the meaning assigned by
Insurance Code §
1467.001.
(3) Claim--A request to a health benefit plan
for payment for health benefits under the terms of the health benefit plan's
coverage, including emergency care, or a health care or medical service or
supply, or any combination of emergency care and health care or medical
services and supplies, provided that the care, services, or supplies:
(A) are furnished for a single date of
service; or
(B) if furnished for
more than one date of service, are provided as a continuing or related course
of treatment over a period of time for a specific medical problem or condition,
or in response to the same initial patient complaint.
(4) Diagnostic imaging provider--Has the
meaning assigned by Insurance Code §
1467.001.
(5) Diagnostic imaging service--Has the
meaning assigned by Insurance Code §
1467.001.
(6) Emergency care--Has the meaning assigned
by Insurance Code §
1301.155, concerning
Emergency Care.
(7) Emergency care
provider--Has the meaning assigned by Insurance Code §
1467.001.
(8) ERISA--The Employee Retirement Income
Security Act of 1974 (29 USC
§
1001 et seq.).
(9) Enrollee--Has the meaning assigned by
Insurance Code §
1467.001.
(10) Facility--Has the meaning assigned by
Health and Safety Code §
324.001,
concerning Definitions.
(11) Health
benefit plan--A plan that provides coverage under:
(A) a health benefit plan offered by an HMO
operating under Insurance Code Chapter 843, concerning Health Maintenance
Organizations;
(B) a preferred
provider benefit plan, including an exclusive provider benefit plan, offered by
an insurer under Insurance Code Chapter 1301, concerning Preferred Provider
Benefit Plans;
(C) a plan, other
than an HMO plan, under Insurance Code Chapters 1551, concerning Texas
Employees Group Benefits Act; 1575, concerning Texas Public School Employees
Group Benefits Program; 1579, concerning Texas School Employees Uniform Group
Health Coverage; or 1682; or
(D) a
self-insured or self-funded plan established by an employer under ERISA for
which the plan sponsor has elected to apply Insurance Code Chapter 1275 to the
plan for the relevant plan year.
(12) Facility-based provider--Has the meaning
assigned by Insurance Code §
1467.001.
(13) Insurer--A life, health, and accident
insurance company; health insurance company; or other company operating under:
Insurance Code Chapters 841, concerning Life, Health, or Accident Insurance
Companies; 842, concerning Group Hospital Service Corporations; 884, concerning
Stipulated Premium Insurance Companies; 885, concerning Fraternal Benefit
Societies; 982, concerning Foreign and Alien Insurance Companies; or 1501,
concerning Health Insurance Portability and Availability Act, that is
authorized to issue, deliver, or issue for delivery in this state a preferred
provider benefit plan, including an exclusive provider benefit plan, under
Insurance Code Chapter 1301.
(14)
Mediation--Has the meaning assigned by Insurance Code §
1467.001.
(15) Mediator--Has the meaning assigned by
Insurance Code §
1467.001.
(16) Out-of-network claim--A claim for
payment for medical or health care services or supplies or both furnished by an
out-of-network provider or a non-network provider.
(17) Out-of-network provider--Has the meaning
assigned by Insurance Code §
1467.001.
(18) Party--Has the meaning assigned by
Insurance Code §
1467.001.
Notes
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