The following words and terms when used in this subchapter
shall have the following meanings unless the context clearly indicates
otherwise.
(1) Board--Texas Medical Board.
(2) Enrollee--An individual who is eligible to receive
benefits through a preferred provider benefit plan offered by an insurer
under the Insurance Code, Chapter 1301 or a health benefit plan, other
than an HMO plan, under the Texas Insurance Code, Chapter 1551.
(3) Facility--a hospital, emergency clinic, outpatient
clinic, birthing center, ambulatory surgical center, or other facility
providing health care services.
(4) Facility-based physician--a radiologist, an anesthesiologist,
a pathologist, an emergency department physician; a neonatologist;
or an assistant surgeon:
(A) to whom the facility has granted clinical privileges;
and
(B) who provides services to patients of the facility
pursuant to those clinical privileges.
(5) Mediation--a process in which an impartial mediator
facilitates and promotes agreement between the insurer offering a
preferred provider benefit plan or the administrator and a facility-based
physician or the physician's representative to settle a health benefit
claim of an enrollee pursuant to Chapter 1467 of the Texas Insurance
Code.
(6) Mediator--an impartial person who is appointed
by the chief administrative law judge at the State Office of Administrative
Hearings to conduct a mediation, pursuant to Chapter 1467 of the Texas
Insurance Code.
(7) Out-of-network health benefit claim--A claim for
payment for medical or health care services that are furnished by
a physician that is not contracted as a preferred provider with a
preferred provider benefit plan or contracted with an administrator.
(8) Qualified health benefit claim--A health benefit
claim that meets all of the criteria under 28 TAC §21.5010(a)
and (b) (relating to Qualified Claim Criteria).
|
