The following words and terms, when used in this subchapter,
have the following meanings, unless the context clearly indicates
otherwise:
(1) Adverse determination--A determination by a utilization
review agent that the health care services furnished or proposed to
be furnished to a patient are not medically necessary or not appropriate.
(2) Complaint--Any dissatisfaction, expressed by a
complainant orally or in writing to the issuer, with any aspect of
the issuer's operation, including plan administration; the denial,
or termination of a service for reasons not related to medical necessity;
the way a service is provided; or disenrollment decisions, expressed
by a complainant. The term does not include a misunderstanding or
problem of misinformation that is resolved promptly by clearing up
the misunderstanding or supplying the appropriate information to the
satisfaction of the insured and does not include a provider's or insured's
oral or written dissatisfaction with an adverse determination.
(3) Credentialing--The process of collecting, assessing,
and validating qualifications and other relevant information pertaining
to a health care provider to determine eligibility to deliver health
care services.
(4) Emergency care--Health care services provided in
a hospital emergency facility or comparable facility to evaluate and
stabilize medical conditions of a recent onset and severity, including
but not limited to severe pain, that would lead a prudent layperson
possessing an average knowledge of medicine and health to believe
that his or her condition, sickness, or injury is of such a nature
that failure to get immediate medical care could result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) in the case of a pregnant woman, serious jeopardy
to the health of the fetus.
(5) Exclusive provider--A health care provider or an
organization of health care providers who contract or subcontract
to provide health care services to covered persons.
(6) Exclusive provider benefit plan (EPP)--A type of
health care plan offered by an issuer that arranges for or provides
benefits to covered persons through a network of exclusive providers,
and that limits or excludes benefits for services provided by other
providers, except in cases of emergency or approved referral.
(7) Health care provider--Any person, corporation,
facility, or institution licensed by the State of Texas (including
physicians and practitioners listed in Insurance Code Chapter 1451)
to provide health care services.
(8) Health care services--Any episodic or ongoing services
such as pharmaceutical, diagnostic, behavioral health, medical, dental
care, or chiropractic in either an inpatient or outpatient setting
rendered by a health care provider for the purpose of treating, preventing,
alleviating, curing, or healing illness, injury, or disease.
(9) Hospital--A licensed public or private institution
as defined in Chapter 241, Health and Safety Code, or in Subtitle
C, Title 7, Health and Safety Code.
(10) Independent review organization--An entity that
is certified by the commissioner to conduct independent review under
the authority of Insurance Code Chapter 4202.
(11) Institutional provider--A hospital, nursing home,
or any other medical or health-related service facility caring for
the sick or injured or providing care for other coverage which may
be provided in a health insurance policy.
(12) Insured--For purposes of this subchapter, a person
covered under an EPP.
(13) Issuer--An insurance company authorized to do
business in Texas that contracts with the Health and Human Services
Commission (HHSC) to provide CHIP or Medicaid coverage or contracts
with or is sponsored by the System to issue an exclusive provider
benefit plan.
(14) Life-threatening--A disease or condition for which
the likelihood of death is probable unless the course of the disease
or condition is interrupted.
(15) Limited provider network--A subnetwork within
a network in which contractual relationships exist between health
care providers, physician associations and/or physician groups which
limit the insureds' access to only those health care providers in
the subnetwork.
(16) Out-of-area benefits--Benefits that the EPP covers
when its insureds are outside the geographical limits of the EPP service
area.
(17) Physician--Anyone licensed to practice medicine
in the State of Texas.
(18) Primary care physician or primary care provider--A
health care provider who has been selected by the insured to provide
initial and primary care, maintain the continuity of patient care,
and who may initiate referrals for care.
(19) Quality improvement--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
(20) Service area--A defined geographic area within
which health care services are available and accessible to EPP insureds
who live, reside, or work within that geographic area.
(21) Urgent care--Health care services provided in
a situation other than an emergency which are typically provided in
settings such as a health care provider's office or urgent care center,
as a result of an acute injury or illness that is severe or painful
enough to lead a prudent layperson, possessing an average knowledge
of medicine and health, to believe that his or her condition, illness,
or injury is of such a nature that failure to obtain treatment within
a reasonable period of time would result in serious deterioration
of the current health condition.
(22) Utilization review--A system for prospective or
concurrent review of the medical necessity and appropriateness of
health care services being provided or proposed to be provided to
an individual within this state. Utilization review will not include
elective requests for clarification of coverage.
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