The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise:
(1) Claims incurred--Paid claims plus amounts held
in reserve for claims that have been incurred but have not yet been
paid.
(2) Direct premium--The amount of health premiums earned
for comprehensive health coverage as reported on an issuer's submission
to the NAIC for the year for which it is reporting data.
(3) Health benefit plan--A health benefit plan regulated
under Insurance Code Title 8 (concerning Health Insurance and Other
Health Coverages), Subtitles A (concerning Health Coverage in General),
B (concerning Group Health Coverage), C (concerning Managed Care),
D (concerning Provider Plans), and G (concerning Health Coverage Availability).
(4) Mandated benefit--A health benefit listed in §21.3406(b)
of this title (relating to Mandates for Which Data Must Be Reported)
that must be included in a health benefit plan.
(5) Mandated offer--An offer of coverage listed in §21.3406(c)
of this title (relating to Mandates for Which Data Must Be Reported)
that must be offered and made available to the holder or sponsor of
an individual or group health benefit plan.
(6) Medical billing codes--Standard code sets used
to bill for specific medical services, including the Healthcare Common
Procedure Coding System (HCPCS) and diagnosis-related group (DRG)
system established by the Centers for Medicare and Medicaid Services
(CMS), the Current Procedural Terminology (CPT) code set maintained
by the American Medical Association, and the International Classification
of Diseases (ICD) code sets developed by the World Health Organization.
TDI's list of suggested mandated benefit codes is shown on its website,
www.tdi.texas.gov.
(7) Member months--The cumulative number of months
that all enrollees were covered during the reporting year.
(8) Reporting entity--A health benefit plan issuer
or a third-party administrator that performs claims payment services
for a health benefit plan issuer to which this subchapter applies.
(9) Reporting year--A one-year period, beginning each
January 1 and ending the following December 31, for which health benefit
plan issuers must collect the data required by §21.3407 of this
title (relating to Reporting of Required Information).
(10) Third-party administrator--An administrator holding
a certificate of authority under Insurance Code Chapter 4151 (concerning
Third-Party Administrators).
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| Source Note: The provisions of this §21.3402 adopted to be effective December 29, 2002, 27 TexReg 11990; amended to be effective December 11, 2003, 28 TexReg 10946; amended to be effective July 6, 2017, 42 TexReg 3384 |
