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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 3LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
SUBCHAPTER XPREFERRED AND EXCLUSIVE PROVIDER PLANS
DIVISION 1GENERAL REQUIREMENTS
RULE §3.3702Definitions

(a) Words and terms defined in Insurance Code Chapter 1301 have the same meaning when used in this subchapter, unless the context clearly indicates otherwise.

(b) The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:

  (1) Adverse determination--As defined in Insurance Code §4201.002(1).

  (2) Allowed amount--The amount of a billed charge that an insurer determines to be covered for services provided by a nonpreferred provider. The allowed amount includes both the insurer's payment and any applicable deductible, copayment, or coinsurance amounts for which the insured is responsible.

  (3) Billed charges--The charges for medical care or health care services included on a claim submitted by a physician or provider.

  (4) Complainant--As defined in §21.2502 of this title (relating to Definitions).

  (5) Complaint--As defined in §21.2502 of this title.

  (6) Contract holder--An individual who holds an individual health insurance policy, or an organization that holds a group health insurance policy.

  (7) Facility--As defined in Health and Safety Code §324.001(7).

  (8) Facility-based physician--A radiologist, an anesthesiologist, a pathologist, an emergency department physician, a neonatologist, or an assistant surgeon:

    (A) to whom a facility has granted clinical privileges; and

    (B) who provides services to patients of the facility under those clinical privileges.

  (9) Health care provider or provider--As defined in Insurance Code §1301.001(1-a).

  (10) Health maintenance organization (HMO)--As defined in Insurance Code §843.002(14).

  (11) In-network--Medical or health care treatment, services, or supplies furnished by a preferred provider, or a claim filed by a preferred provider for the treatment, services, or supplies.

  (12) NCQA--The National Committee for Quality Assurance, which reviews and accredits managed care plans.

  (13) Nonpreferred provider--A physician or health care provider, or an organization of physicians or health care providers, that does not have a contract with the insurer to provide medical care or health care on a preferred benefit basis to insureds covered by a health insurance policy issued by the insurer.

  (14) Out-of-network--Medical or health care treatment services, or supplies furnished by a nonpreferred provider, or a claim filed by a nonpreferred provider for the treatment, services, or supplies.

  (15) Pediatric practitioner--A physician or provider with appropriate education, training, and experience whose practice is limited to providing medical and health care services to children and young adults.

  (16) Provider network--The collective group of physicians and health care providers available to an insured under a preferred or exclusive provider benefit plan and directly or indirectly contracted with the insurer of a preferred or exclusive provider benefit plan to provide medical or health care services to individuals insured under the plan.

  (17) Rural area --

    (A) a county with a population of 50,000 or less as determined by the United States Census Bureau in the most recent decennial census report;

    (B) an area that is not designated as an urbanized area by the United States Census Bureau in the most recent decennial census report; or

    (C) any other area designated as rural under rules adopted by the , notwithstanding subparagraphs (A) and (B) of this paragraph.

  (18) Urgent care--Medical or 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 the person's 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 condition of the person's health.

  (19) Utilization review--As defined in Insurance Code §4201.002(13).


Source Note: The provisions of this §3.3702 adopted to be effective July 1, 1986, 11 TexReg 2810; amended to be effective December 28, 1990, 15 TexReg 7183; amended to be effective December 6, 1995, 20 TexReg 9697; amended to be effective June 1, 1996, 21 TexReg 2465; amended to be effective July 15, 1999, 24 TexReg 5204; amended to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827; amended to be effective March 30, 2021, 46 TexReg 2026

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