The following words and terms when used in this subchapter
have the following meanings unless the context clearly indicates otherwise:
(1) Allowed amount--The amount that the applicable
health benefit plan issuer allows as payment for a health care service
or group of services, including amounts for which a patient is responsible
due to deductibles, copayments, or coinsurance.
(2) Ambulatory surgical center--A facility licensed
under Health and Safety Code Chapter 243.
(3) Applicable health benefit plan--A group health
benefit plan as specified in Insurance Code §38.352 and §38.353,
which is a preferred provider benefit plan as defined by Insurance
Code §1301.001, including an exclusive provider benefit plan
consistent with Insurance Code §1301.0042, or an evidence of
coverage for a health care plan that provides basic health care services
as defined by Insurance Code §843.002, or a state employee health
plan under Insurance Code Chapters 1551, 1575, 1579, and 1601. The
term does not include an HMO plan providing routine dental or vision
services as a single health care service plan or a preferred provider
benefit plan providing routine vision services as a single health
care service plan.
(4) Billed amount--The amount charged for health care
services on a claim submitted by a provider.
(5) Facility claims--Any claim for health care services
provided by a facility as defined in §3.3702 of this title.
(6) Freestanding emergency medical care facility--A
freestanding emergency medical care facility required to be licensed
under Health and Safety Code Chapter 254.
(7) Geographic region--A three-digit ZIP code representing
the collection of ZIP codes that share the same first three digits.
For purposes of data submitted under this subchapter, a geographic
region must be located in Texas, in full or in part.
(8) Imaging claims--Claims for radiological services
furnished in a provider office, outpatient hospital, or other outpatient
environment.
(9) Inpatient procedure claims--Claims for health care
services furnished in a hospital, as defined by Insurance Code §1301.001,
to a patient who is formally admitted.
(10) In-network claims--Claims filed with an applicable
health benefit plan for health care treatment, services, or supplies
furnished by a provider contracted as an in-network or preferred provider
under the plan.
(11) 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.
(12) Out-of-network claims--Claims filed with an applicable
health benefit plan for health care treatment, services, or supplies
furnished by a provider that is not an in-network provider or preferred
provider under the plan. Claims paid on an out-of-network basis are
considered out-of-network regardless of whether the provider is reimbursed
based on an agreed on rate.
(13) Outpatient facility procedure claims--Claims for
health care services furnished in an ambulatory surgical center or
a hospital, as defined by Insurance Code §1301.001, to a patient
who is not formally admitted.
(14) Place-of-service code--A health care claim code
where "place of service" refers to the type of entity where services
were rendered, as specified by a two-digit place-of-service code on
a professional health care claim consistent with the ASC X12N standard
for electronic transactions. Place-of-service codes are maintained
by CMS.
(15) Primary plan--As defined in §3.3503(17) of
this title.
(16) Professional claims--Any claim for health care
services provided by a physician or provider that is not an institutional
provider, as defined in Insurance Code §1301.001.
(17) Provider--Any physician, practitioner, institutional
provider, or other person or organization that furnishes health care
services and is licensed or otherwise authorized to practice in this
state.
(18) Reporting period--The 12-month interval of time
for which a plan or applicable health benefit plan issuer must submit
data each year, beginning each January 1 and ending the following
December 31.
(19) TDI--Texas Department of Insurance.
|
