The following words and terms have the following meanings when
used in this subchapter unless the context clearly indicates otherwise.
(1) Administrator--Has the meaning assigned by Insurance
Code §1467.001, concerning Definitions. The term also includes
an administrator of a nonprofit agricultural organization under Insurance
Code Chapter 1682, concerning Health Benefits Provided by Certain
Nonprofit Agricultural Organizations, and an administrator of a self-insured
or self-funded ERISA plan under Insurance Code Chapter 1275, concerning
Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution
for Certain Plans, offering a health benefit plan.
(2) Arbitration--Has the meaning assigned by Insurance
Code §1467.001.
(3) Claim--A request to a health benefit plan for payment
for health benefits under the terms of the health benefit plan's coverage,
including emergency care, or a health care or medical service or supply,
or any combination of emergency care and health care or medical services
and supplies, provided that the care, services, or supplies:
(A) are furnished for a single date of service; or
(B) if furnished for more than one date of service,
are provided as a continuing or related course of treatment over a
period of time for a specific medical problem or condition, or in
response to the same initial patient complaint.
(4) Diagnostic imaging provider--Has the meaning assigned
by Insurance Code §1467.001.
(5) Diagnostic imaging service--Has the meaning assigned
by Insurance Code §1467.001.
(6) Emergency care--Has the meaning assigned by Insurance
Code §1301.155, concerning Emergency Care.
(7) Emergency care provider--Has the meaning assigned
by Insurance Code §1467.001.
(8) ERISA--The Employee Retirement Income Security
Act of 1974 (29 USC §1001 et seq.).
(9) Enrollee--Has the meaning assigned by Insurance
Code §1467.001.
(10) Facility--Has the meaning assigned by Health and
Safety Code §324.001, concerning Definitions.
(11) Health benefit plan--A plan that provides coverage
under:
(A) a health benefit plan offered by an HMO operating
under Insurance Code Chapter 843, concerning Health Maintenance Organizations;
(B) a preferred provider benefit plan, including an
exclusive provider benefit plan, offered by an insurer under Insurance
Code Chapter 1301, concerning Preferred Provider Benefit Plans;
(C) a plan, other than an HMO plan, under Insurance
Code Chapters 1551, concerning Texas Employees Group Benefits Act;
1575, concerning Texas Public School Employees Group Benefits Program;
1579, concerning Texas School Employees Uniform Group Health Coverage;
or 1682; or
(D) a self-insured or self-funded plan established
by an employer under ERISA for which the plan sponsor has elected
to apply Insurance Code Chapter 1275 to the plan for the relevant
plan year.
(12) Facility-based provider--Has the meaning assigned
by Insurance Code §1467.001.
(13) Insurer--A life, health, and accident insurance
company; health insurance company; or other company operating under:
Insurance Code Chapters 841, concerning Life, Health, or Accident
Insurance Companies; 842, concerning Group Hospital Service Corporations;
884, concerning Stipulated Premium Insurance Companies; 885, concerning
Fraternal Benefit Societies; 982, concerning Foreign and Alien Insurance
Companies; or 1501, concerning Health Insurance Portability and Availability
Act, that is authorized to issue, deliver, or issue for delivery in
this state a preferred provider benefit plan, including an exclusive
provider benefit plan, under Insurance Code Chapter 1301.
(14) Mediation--Has the meaning assigned by Insurance
Code §1467.001.
(15) Mediator--Has the meaning assigned by Insurance
Code §1467.001.
(16) Out-of-network claim--A claim for payment for
medical or health care services or supplies or both furnished by an
out-of-network provider or a non-network provider.
(17) Out-of-network provider--Has the meaning assigned
by Insurance Code §1467.001.
(18) Party--Has the meaning assigned by Insurance Code §1467.001.
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| Source Note: The provisions of this §21.5003 adopted to be effective October 19, 2010, 35 TexReg 9300; amended to be effective November 3, 2016, 41 TexReg 8612; amended to be effective April 26, 2018, 43 TexReg 2423; amended to be effective December 23, 2019, 44 TexReg 7988; amended to be effective February 20, 2022, 47 TexReg 792; amended to be effective January 3, 2024, 48 TexReg 8372 |
