28 Tex. Admin. Code § 3.9202 - Definitions
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
(1) Adverse
determination--A determination by a utilization review agent that the health
care services furnished or proposed to be furnished to a patient are not
medically necessary or not appropriate.
(2) Complaint--Any dissatisfaction, expressed
by a complainant orally or in writing to the issuer, with any aspect of the
issuer's operation, including plan administration; the denial, or termination
of a service for reasons not related to medical necessity; the way a service is
provided; or disenrollment decisions, expressed by a complainant. The term does
not include a misunderstanding or problem of misinformation that is resolved
promptly by clearing up the misunderstanding or supplying the appropriate
information to the satisfaction of the insured and does not include a
provider's or insured's oral or written dissatisfaction with an adverse
determination.
(3)
Credentialing--The process of collecting, assessing, and validating
qualifications and other relevant information pertaining to a health care
provider to determine eligibility to deliver health care services.
(4) Emergency care--Health care services
provided in a hospital emergency facility or comparable facility to evaluate
and stabilize medical conditions of a recent onset and severity, including but
not limited to severe pain, that would lead a prudent layperson possessing an
average knowledge of medicine and health to believe that his or her condition,
sickness, or injury is of such a nature that failure to get immediate medical
care could result in:
(A) placing the
patient's health in serious jeopardy;
(B) serious impairment to bodily
functions;
(C) serious dysfunction
of any bodily organ or part;
(D)
serious disfigurement; or
(E) in
the case of a pregnant woman, serious jeopardy to the health of the
fetus.
(5) Exclusive
provider--A health care provider or an organization of health care providers
who contract or subcontract to provide health care services to covered
persons.
(6) Exclusive provider
benefit plan (EPP)--A type of health care plan offered by an issuer that
arranges for or provides benefits to covered persons through a network of
exclusive providers, and that limits or excludes benefits for services provided
by other providers, except in cases of emergency or approved
referral.
(7) Health care
provider--Any person, corporation, facility, or institution licensed by the
State of Texas (including physicians and practitioners listed in Insurance Code
Chapter 1451) to provide health care services.
(8) Health care services--Any episodic or
ongoing services such as pharmaceutical, diagnostic, behavioral health,
medical, dental care, or chiropractic in either an inpatient or outpatient
setting rendered by a health care provider for the purpose of treating,
preventing, alleviating, curing, or healing illness, injury, or
disease.
(9) Hospital--A licensed
public or private institution as defined in Chapter 241, Health and Safety
Code, or in Subtitle C, Title 7, Health and Safety Code.
(10) Independent review organization--An
entity that is certified by the commissioner to conduct independent review
under the authority of Insurance Code Chapter 4202.
(11) Institutional provider--A hospital,
nursing home, or any other medical or health-related service facility caring
for the sick or injured or providing care for other coverage which may be
provided in a health insurance policy.
(12) Insured--For purposes of this
subchapter, a person covered under an EPP.
(13) Issuer--An insurance company authorized
to do business in Texas that contracts with the Health and Human Services
Commission (HHSC) to provide CHIP or Medicaid coverage or contracts with or is
sponsored by the System to issue an exclusive provider benefit plan.
(14) Life-threatening--A disease or condition
for which the likelihood of death is probable unless the course of the disease
or condition is interrupted.
(15)
Limited provider network--A subnetwork within a network in which contractual
relationships exist between health care providers, physician associations
and/or physician groups which limit the insureds' access to only those health
care providers in the subnetwork.
(16) Out-of-area benefits--Benefits that the
EPP covers when its insureds are outside the geographical limits of the EPP
service area.
(17)
Physician--Anyone licensed to practice medicine in the State of
Texas.
(18) Primary care physician
or primary care provider--A health care provider who has been selected by the
insured to provide initial and primary care, maintain the continuity of patient
care, and who may initiate referrals for care.
(19) Quality improvement--A system to
continuously examine, monitor, and revise processes and systems that support
and improve administrative and clinical functions.
(20) Service area--A defined geographic area
within which health care services are available and accessible to EPP insureds
who live, reside, or work within that geographic area.
(21) Urgent care--Health care services
provided in a situation other than an emergency which are typically provided in
settings such as a health care 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 his or her 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 current health condition.
(22) Utilization review--A system for
prospective or concurrent review of the medical necessity and appropriateness
of health care services being provided or proposed to be provided to an
individual within this state. Utilization review will not include elective
requests for clarification of coverage.
Notes
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