28 Tex. Admin. Code § 3.3702 - Definitions
(a) Words and terms defined in Insurance Code
Chapter 1301, concerning Preferred Provider Benefit Plans, have the same
meaning when used in this subchapter, unless the context clearly indicates
otherwise.
(b) The following words
and terms, when used in this subchapter, have the following meanings, unless
the context clearly indicates otherwise:
(1)
Adverse determination--As defined in Insurance Code §
4201.002(1),
concerning Definitions.
(2) Allowed
amount--The amount of a billed charge that an insurer determines to be covered
for services provided by a nonpreferred provider. The allowed amount includes
both the insurer's payment and any applicable deductible, copayment, or
coinsurance amounts for which the insured is responsible.
(3) Billed charges--The charges for medical
care or health care services included on a claim submitted by a physician or
provider.
(4) Complainant--As
defined in §
21.2502 of this title (relating to
Definitions).
(5) Complaint--As
defined in §
21.2502 of this title.
(6) Contract holder--An individual who holds
an individual health insurance policy, or an organization that holds a group
health insurance policy.
(7)
Facility--As defined in Health and Safety Code §
324.001(7),
concerning Definitions.
(8)
Facility-based physician or provider--As defined in Insurance Code §
1451.501, concerning
Definitions.
(9) Health care
provider or provider--As defined in Insurance Code §
1301.001
(1-a).
(10) Health maintenance
organization (HMO)--As defined in Insurance Code §
843.002(14),
concerning Definitions.
(11)
In-network--Medical or health care treatment, services, or supplies furnished
by a preferred provider, or a claim filed by a preferred provider for the
treatment, services, or supplies.
(12) NCQA--The National Committee for Quality
Assurance, which reviews and accredits managed care plans.
(13) Nonpreferred provider--A physician or
health care provider, or an organization of physicians or health care
providers, that does not have a contract with the insurer to provide medical
care or health care on a preferred benefit basis to insureds covered by a
health insurance policy issued by the insurer.
(14) Out-of-network--Medical or health care
treatment services, or supplies furnished by a nonpreferred provider, or a
claim filed by a nonpreferred provider for the treatment, services, or
supplies.
(15) Pediatric
practitioner--A physician or provider with appropriate education, training, and
experience whose practice is limited to providing medical and health care
services to children and young adults.
(16) Provider network--The collective group
of physicians and health care providers available to an insured under a
preferred or exclusive provider benefit plan and directly or indirectly
contracted with the insurer of a preferred or exclusive provider benefit plan
to provide medical or health care services to individuals insured under the
plan.
(17) SERFF--The National
Association of Insurance Commissioners (NAIC) System for Electronic Rates &
Forms Filing.
(18) Urgent
care--Medical or health care services provided in a situation other than an
emergency that are typically provided in a setting such as a physician or
individual provider's office or urgent care center, as a result of an acute
injury or illness that is severe or painful enough to lead a prudent layperson,
possessing an average knowledge of medicine and health, to believe that the
person's condition, illness, or injury is of such a nature that failure to
obtain treatment within a reasonable period of time would result in serious
deterioration of the condition of the person's health.
(19) Utilization review--As defined in
Insurance Code §
4201.002(13).
Notes
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