The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Affiliate--As defined in Insurance Code §848.001(1).
(2) Clinical director--Health professional who is:
(A) appropriately licensed in good standing in Texas;
(B) an employee of, or party to a contract with, an
HCC; and
(C) responsible for clinical oversight of the utilization
review program, the credentialing of professional staff, and quality
improvement functions.
(3) Common service--An identical or substantially similar
health care service provided to patients by two or more independent
HCC participants.
(4) Confidential information--Information that relates
to bidding, pricing, trade secrets, business planning documents, financial
position and related operational results, profit and loss statements,
contracts, salaries, employee benefits, or other competitively sensitive
information.
(5) Credentialing--The periodic process of collecting,
assessing, and validating qualifications and other relevant information
pertaining to a physician or health care provider to determine eligibility
to deliver health care services.
(6) Entity--An artificial person, including a partnership,
association, organization, trust, or corporation; the term does not
include a securities broker performing no more than the usual and
customary broker's function.
(7) Facility--
(A) an ambulatory surgical center licensed under Health
and Safety Code Chapter 243;
(B) a birthing center licensed under Health and Safety
Code Chapter 244; or
(C) a hospital licensed under Health and Safety Code
Chapter 241 or 577.
(8) Financial statement--An HCC's annual statement
of financial position and operating results, including a balance sheet,
receipts, and disbursements, certified by an independent certified
public accountant and prepared in accord with Generally Accepted Accounting
Principles.
(9) Health care collaborative or HCC--As defined in
Insurance Code §848.001(2).
(10) Health care provider--As defined in Insurance
Code §848.001(4).
(11) Health care services--As defined in Insurance
Code §848.001(3).
(12) Health maintenance organization or HMO--As defined
in Insurance Code §848.001(5).
(13) Hospital--As defined in Insurance Code §848.001(6).
(14) Individual--A natural person.
(15) Individual health care provider--A health care
provider who is a natural person.
(16) Network--A health care delivery system in which
an HCC provides or arranges to provide health care services directly
or through contracts and subcontracts with governmental entities or
private individuals or entities.
(17) Participant--Each physician or health care provider
that has agreed to participate in the HCC.
(18) Patient--An individual who receives a health care
service.
(19) Physician--As defined in Insurance Code §848.001(8).
(20) Primary service area or PSA--For each common service
and each participant, the area defined by the smallest number of postal
ZIP codes from which the participant draws at least 75 percent of
its patients for that service.
(21) Private payor--Any of the following:
(A) an insurer that writes health insurance policies;
(B) an HMO, to the extent that it pays physicians or
health care providers for health care services under an HMO evidence
of coverage or under a negotiated-rate contract with the physician
or health care provider; or
(C) any other entity, including an insurer or third-party
administrator for self-insured private or governmental employers,
that provides, or offers to provide, health care services to a patient
pursuant to a negotiated-rate contract that the entity negotiated
with physicians or health care providers.
(22) Pro-competitive benefit--A benefit obtained from
clinical or financial integration by the establishment and operation
of the HCC that ultimately accrues to the benefit of the HCC's patients.
A pro-competitive benefit may include use of electronic medical records,
implementation of quality control procedures, utilization review,
clinical protocols, coordination of care, and financial incentives
to reduce costs or increase quality.
(23) Quality improvement or QI--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
(24) Rural hospital--A hospital:
(A) that is paid under the Medicare hospital inpatient
prospective payment system and is either located more than 35 miles
from other like hospitals or is located in a rural area, and meets
the criteria for sole community hospital status as specified by 42
CFR §412.92; or
(B) located in a rural area and that has been certified
as a Medicare critical access hospital based on the criteria set forth
in 42 CFR Part 485, Subpart F.
(25) Service area--A geographic area within which health
care services are available and accessible to an HCC's patients who
live, reside, or work within that geographic area and that complies
with §13.473 of this title (relating to Organization of an HCC).
(26) Utilization review--As defined in Insurance Code §4201.002.
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