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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 10WORKERS' COMPENSATION HEALTH CARE NETWORKS
SUBCHAPTER AGENERAL PROVISIONS AND DEFINITIONS
RULE §10.2Definitions

(a) The following words and terms when used in this chapter shall have the following meanings, unless the context clearly indicates otherwise.

  (1) Adverse determination--A determination, made through utilization review or retrospective review, that the health care services furnished or proposed to be furnished to an employee are not medically necessary or appropriate.

  (2) Affiliate--A person that directly, or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, the person specified.

  (3) Capitation--A method of compensation for arranging for or providing health care services to employees for a specified period that is based on a predetermined payment for each employee for the specified period, without regard to the quantity of services provided for the compensable injury.

  (4) Complainant--A person who files a complaint under this chapter. The term includes:

    (A) an employee;

    (B) an employer;

    (C) a health care provider; and

    (D) another person designated to act on behalf of an employee.

  (5) Complaint--Any dissatisfaction expressed orally or in writing by a complainant to a network regarding any aspect of the network's operation. The term includes dissatisfaction relating to medical fee disputes and the network's administration and the manner in which a service is provided. The term does not include:

    (A) a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the complainant; or

    (B) an oral or written expression of dissatisfaction or disagreement with an adverse determination.

  (6) Credentialing--The review, under nationally recognized standards to the extent that those standards do not conflict with other laws of this state, of qualifications and other relevant information relating to a health care provider who seeks a contract with a network.

  (7) Emergency--Either a medical or mental health emergency.

  (8) Employee--Has the meaning assigned by Labor Code §401.012.

  (9) Fee dispute--A dispute over the amount of payment due for health care services determined to be medically necessary and appropriate for treatment of a compensable injury.

  (10) HMO--A health maintenance organization licensed and regulated under Insurance Code Chapter 843.

  (11) Independent review--A system for final administrative review by an independent review organization of the medical necessity and appropriateness of health care services being provided, proposed to be provided, or that have been provided to an employee.

  (12) Independent review organization--An entity that is certified by the commissioner to conduct independent review under Insurance Code Article 21.58C and rules adopted by the commissioner.

  (13) Life-threatening--Has the meaning assigned by Insurance Code Article 21.58A §2.

  (14) Live--Where an employee lives includes:

    (A) the employee's principal residence for legal purposes, including the physical address which 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.

  (15) Medical emergency--The sudden onset of a medical condition manifested by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in:

    (A) placing the patient's health or bodily functions in serious jeopardy; or

    (B) serious dysfunction of any body organ or part.

  (16) Medical records--The history of diagnosis and treatment for an injury, including medical, dental, and other health care records from each health care practitioner who provides care to an injured employee.

  (17) Mental health emergency--A condition that could reasonably be expected to present danger to the person experiencing the mental health condition or another person.

  (18) Network or workers' compensation health care network--An organization that is:

    (A) formed as a health care provider network to provide or arrange to provide health care services to injured employees;

    (B) required to be certified in accordance with Insurance Code Chapter 1305, this chapter, and other rules of the commissioner as applicable; and

    (C) established by, or operating under contract with, an insurance carrier.

  (19) Nurse--Has the meaning assigned by Insurance Code Article 21.58A §2.

  (20) 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.

  (21) Person--Any natural or artificial person, including an individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, mental retardation center, mental health and mental retardation center, limited liability company, or limited liability partnership.

  (22) Preauthorization--The process required to request approval from the insurance carrier or the network to provide a specific treatment or service before the treatment or service is provided.

  (23) Provider--A health care provider.

  (24) Quality improvement program--A system designed to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.

  (25) Retrospective review--The process of reviewing the medical necessity and reasonableness of health care that has been provided to an injured employee.

  (26) Routine daily activities--Activities a person normally does in daily living, including sleeping, eating, bathing, dressing, grooming, and homemaking.

  (27) Rural area--

    (A) a county with a population of 50,000 or less;

    (B) an area that is not designated as an urbanized area by the United States Census Bureau; or

    (C) any other area designated as rural under rules adopted by the commissioner.

  (28) Screening criteria--The written policies, medical protocols, and treatment guidelines used by an insurance carrier or a network as part of utilization review or retrospective review.

  (29) Service area--A geographic area within which health care services from network providers are available and accessible to employees who live within that geographic area.

  (30) Texas Workers' Compensation Act--Labor Code Title 5 Subtitle A.

  (31) Transfer of risk--For purposes of this chapter only, an insurance carrier's transfer of financial risk for the provision of health care services to a network through capitation or other means.

  (32) Utilization review--Has the meaning assigned by Insurance Code Article 21.58A §2.

  (33) Utilization review agent--Has the meaning assigned by Insurance Code Article 21.58A §2.

(b) 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) injury;

  (12) insurance carrier; and

  (13) treating doctor.


Source Note: The provisions of this §10.2 adopted to be effective December 5, 2005, 30 TexReg 8099

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