| (a) The following words and terms when used in this
chapter have the following meanings unless the context clearly indicates
otherwise.
(1) Administrator--Has the meaning assigned by Insurance
Code §4151.001, concerning Definitions.
(2) Adverse determination--A determination by a URA
made on behalf of a payor that the health care services provided or
proposed to be provided to an injured employee are not medically necessary
or appropriate. The term does not include a denial of health care
services due to the failure to request prospective or concurrent utilization
review. For the purposes of this subchapter, an adverse determination
does not include a determination that health care services are experimental
or investigational.
(3) Affiliate--Has the meaning assigned by Insurance
Code §1305.004, concerning Definitions.
(4) Capitation--Has the meaning assigned by Insurance
Code §1305.004. The term includes predetermined payment to cover
the average costs of services for a defined episode of care.
(5) Complainant--Has the meaning assigned by Insurance
Code §1305.004.
(6) Complaint--Has the meaning assigned by Insurance
Code §1305.004.
(7) Concurrent utilization review--A form of utilization
review for ongoing health care or for an extension of treatment beyond
previously approved health care.
(8) Credentialing--Has the meaning assigned by Insurance
Code §1305.004.
(9) Division of Workers' Compensation--Has the meaning
assigned to the "Division" by Labor Code §401.011, concerning
General Definitions.
(10) Emergency--Has the meaning assigned by Insurance
Code §1305.004.
(11) Employee--Has the meaning assigned by Labor Code §401.012,
concerning Definition of Employee.
(12) Fee dispute--Has the meaning assigned by Insurance
Code §1305.004.
(13) HMO--A health maintenance organization licensed
and regulated under Insurance Code Chapter 843, concerning Health
Maintenance Organizations.
(14) Independent review--Has the meaning assigned by
Insurance Code §1305.004.
(15) Independent review organization--Has the meaning
assigned by Insurance Code §1305.004.
(16) Life-threatening--Has the meaning assigned by
Insurance Code Chapter 4201, concerning Utilization Review Agents.
(17) Live or lives--Where an employee lives includes:
(A) the employee's principal residence for legal purposes,
including the physical address that the employee represented to the
employer as the employee's address;
(B) a temporary residence necessitated by employment;
or
(C) a temporary residence taken by the employee primarily
for the purpose of receiving necessary assistance with routine daily
activities because of a compensable injury.
(18) MCQA--The Office of Managed Care Quality Assurance,
or a successor office at the department.
(19) Medical emergency--Has the meaning assigned by
Insurance Code §1305.004.
(20) Medical records--Has the meaning assigned by Insurance
Code §1305.004.
(21) Mental health emergency--Has the meaning assigned
by Insurance Code §1305.004.
(22) Network or workers' compensation health care network--Has
the meaning assigned by Insurance Code §1305.004.
(23) Occupational medicine specialist--A doctor who
has received a board certification in occupational medicine from the
American Board of Preventive Medicine or who has completed all the
requirements of the American Board of Preventive Medicine in order
to take the board examination.
(24) Person--Has the meaning assigned by Insurance
Code §1305.004.
(25) Physician--Has the meaning assigned by Insurance
Code §4201.002, concerning Definitions.
(26) Preauthorization--A form of prospective utilization
review by a payor or a payor's URA of health care services proposed
to be provided to an injured employee.
(27) Provider--A health care provider.
(28) Quality improvement program--Has the meaning assigned
by Insurance Code §1305.004.
(29) Retrospective review--A form of utilization review
for health care services that have been provided to an injured employee.
Retrospective review does not include review of services for which
prospective or concurrent utilization reviews were previously conducted
or should have been previously conducted.
(30) Routine daily activities""Activities a person
normally does in daily living, including sleeping, eating, bathing,
dressing, grooming, and homemaking.
(31) Rural area--Has the meaning assigned by Insurance
Code §1305.004.
(32) Screening criteria--Has the meaning assigned by
Insurance Code §1305.004.
(33) Service area--Has the meaning assigned by Insurance
Code §1305.004.
(34) Telehealth service, telemedicine medical service,
and teledentistry dental service--Have the meanings assigned by Occupations
Code §111.001, concerning Definitions.
(35) Transfer of risk--Has the meaning assigned by
Insurance Code §1305.004.
(36) Utilization review--Has the meaning assigned by
Insurance Code Chapter 4201.
(37) Utilization review agent or URA--Has the meaning
assigned by Insurance Code Chapter 4201.
(b) When used in this chapter, the following terms
have the meanings assigned by Labor Code §401.011:
(1) administrative violation;
(2) case management;
(3) compensable injury;
(4) doctor;
(5) employer;
(6) evidence-based medicine;
(7) health care;
(8) health care facility;
(9) health care practitioner;
(10) health care provider;
(11) impairment rating;
(12) injury;
(13) insurance carrier;
(14) maximum medical improvement; and
(15) treating doctor.
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