| (32) Out of area benefits or services--Benefits or
services that an HMO covers when enrollees are outside the geographical
limits of the HMO service area.
(33) Pharmaceutical services--Services, including dispensing
prescription drugs, under the Texas Pharmacy Act, Occupations Code,
Title 3, Subtitle J, Chapters 551 - 569 (concerning Pharmacy and Pharmacists),
that are ordinarily and customarily rendered by a pharmacy or pharmacist.
(34) Pharmacist--An individual provider licensed to
practice pharmacy under the Texas Pharmacy Act, Occupations Code,
Title 3, Subtitle J, Chapters 551 - 569.
(35) Pharmacy--A facility licensed under the Texas
Pharmacy Act, Occupations Code, Title 3, Subtitle J, Chapters 551
- 569.
(36) Preauthorization--As defined in Insurance Code
§843.348(a) (concerning Preauthorization of Health Care Services).
(37) Premium--All amounts payable by a contract holder
as a condition of receiving coverage from a carrier, including any
fees or other contributions associated with a health benefit plan.
(38) Primary care physician or primary care provider--A
physician or individual provider who is responsible for providing
initial and primary care to patients, maintaining the continuity of
patient care, and initiating referral for care.
(39) Primary HMO--An HMO that contracts directly with,
and issues an evidence of coverage to, individuals or organizations
to arrange for or provide a basic, limited, or single health care
service plan to enrollees on a prepaid basis.
(40) Provider HMO--An HMO that contracts directly with
a primary HMO to provide or arrange to provide health care services
on behalf of the primary HMO within the primary HMO's defined service
area.
(41) Psychiatric hospital--A licensed hospital that
offers inpatient services, including treatment, facilities, and beds
for use beyond 24 hours, for the primary purpose of providing psychiatric
assessment, psychiatric diagnostic services, psychiatric inpatient
care, and treatment for mental illness. The services must be more
intensive than room, board, personal services, and general medical
and nursing care. Although substance abuse services may be offered,
a majority of beds must be dedicated to the treatment of mental illness
in adults, children, or both.
(42) QI or quality improvement--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
(43) Recredentialing--The periodic process by which:
(A) qualifications of physicians and providers are
reassessed;
(B) performance indicators, including utilization and
quality indicators, are evaluated; and
(C) continued eligibility to provide services is determined.
(44) Schedule of charges--Specific rates or premiums
to be charged for enrollee and dependent coverages.
(45) Service area--A geographic area within which
direct service benefits are available and accessible to HMO enrollees
who live, reside, or work within that geographic area and that complies
with §11.1606 of this title.
(46) Single service HMO--An HMO that has been issued
a certificate of authority to issue a single health care service plan
as defined in Insurance Code §843.002.
(47) Special hospital--An establishment, licensed under
Health and Safety Code Chapter 241 (concerning Hospitals), that:
(A) offers services, facilities, and beds for use for
more than 24 hours for two or more unrelated individuals who are regularly
admitted, treated, and discharged and who require services more intensive
than room, board, personal services, and general nursing care;
(B) has clinical laboratory facilities, diagnostic
X-ray facilities, treatment facilities, or other definitive medical
treatment;
(C) has a medical staff in regular attendance; and
(D) maintains records of the clinical work performed
for each patient.
(48) Specialists--Physicians or individual providers
who set themselves apart from the primary care physician or primary
care provider through specialized training and education in a health
care discipline.
(49) State-mandated health benefit plan--An accident
or sickness insurance policy or evidence of coverage that provides
state-mandated health benefits as defined in §21.3502 of this
title (relating to Definitions).
(50) Subscriber--For conversion or individual coverage,
the individual who is the contract holder and is responsible for payment
of premiums to the HMO. For group coverage, the individual who is
the certificate holder and whose employment or other membership status,
except for family dependency, is the basis for eligibility for enrollment
in the HMO.
(51) Subsidiary--As defined in §7.202 of this
title.
(52) Telehealth service--As defined in Government Code
§531.001 (concerning Definitions).
(53) Telemedicine medical service--As defined in Government
Code §531.001.
(54) Urgent care--Health care services provided in
a situation other than an emergency that are typically provided in
a setting such as a physician or individual 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 time would result in serious deterioration of
the condition of his or her health.
(55) Utilization review--As defined in Insurance Code
§4201.002 (concerning Definitions).
(56) Utilization review agent or URA--As defined in
Insurance Code §4201.002.
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