The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise:
(1) CDT--Current Dental Terminology code set maintained
by the American Dental Association.
(2) CPT--Current Procedural Terminology code set maintained
by the American Medical Association.
(3) Department or TDI--Texas Department of Insurance.
(4) Form--In Division 2 of this subchapter, the Texas
Standard Prior Authorization Request Form for Health Care Services.
In Division 3 of this subchapter, the Texas Standard Prior Authorization
Request Form for Prescription Drug Benefits.
(5) HCPCS--Healthcare Common Procedure Coding System.
(6) Health benefit plan--
(A) a plan that provides benefits for medical or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or a small or large employer group contract or similar coverage document
offered by a health benefit plan issuer.
(B) Health benefit plan also includes:
(i) group health coverage made available by a school
district in accord with Education Code §22.004;
(ii) coverage under the child health program in Health
and Safety Code Chapter 62, or the health benefits plan for children
in Health and Safety Code Chapter 63;
(iii) a Medicaid managed care program operated under
Government Code Chapter 533, or a Medicaid program operated under
Human Resources Code Chapter 32;
(iv) a basic coverage plan under Insurance Code Chapter
1551;
(v) a basic plan under Insurance Code Chapter 1575;
(vi) a primary care coverage plan under Insurance Code
Chapter 1579; and
(vii) basic coverage under Insurance Code Chapter 1601.
(7) Health benefit plan issuer--An entity authorized
under the Insurance Code or another insurance law of this state that
delivers or issues for delivery a health benefit plan or other coverage
described in Insurance Code §1217.002 or Insurance Code §1369.252.
(8) Health care service--A service to diagnose, prevent,
alleviate, cure, or heal a human illness or injury that is provided
by a physician or other health care provider. The term includes medical
or health care treatments, consultations, procedures, drugs, supplies,
imaging and diagnostic services, inpatient and outpatient care, medical
devices other than those included in the definition of prescription
drugs in Occupations Code §551.003, and durable medical equipment.
The term does not include prescription drugs or devices as defined
by Occupations Code §551.003.
(9) ICD--International Classification of Diseases.
(10) Issuer--A health benefit plan issuer and the agent
of a health benefit plan issuer that manages or administers the issuer's
health care services or prescription drug benefits.
(11) NDC--National Drug Code.
(12) NPI number--A provider's or facility's National
Provider Identifier.
(13) Prescription drug--Has the meaning assigned by
Occupations Code §551.003.
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| Source Note: The provisions of this §19.1803 adopted to be effective September 1, 2015, 39 TexReg 9699; amended to be effective September 1, 2015, 40 TexReg 2193; amended to be effective August 11, 2022, 47 TexReg 4681 |
