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RULE §19.1703Definitions

(a) The words and terms defined in Insurance Code Chapter 4201 have the same meaning when used in this subchapter, except as otherwise provided by 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--A determination by a URA made on behalf of any payor that the health care services provided or proposed to be provided to an enrollee are not medically necessary or appropriate or are experimental or investigational. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review.

  (2) Appeal--A URA's formal process by which an enrollee, an individual acting on behalf of an enrollee, or an enrollee's provider of record may request reconsideration of an adverse determination.

  (3) Biographical affidavit--National Association of Insurance Commissioners biographical affidavit to be used as an attachment to the URA application.

  (4) Certificate--A certificate issued by the commissioner to an entity authorizing the entity to operate as a URA in the State of Texas. A certificate is not issued to an insurance carrier or health maintenance organization that is registered as a URA under §19.1704 of this title (relating to Certification or Registration of URAs).

  (5) Commissioner--As defined in Insurance Code §31.001.

  (6) Complaint--An oral or written expression of dissatisfaction with a URA concerning the URA's process in conducting a utilization review. The term "complaint" does not include:

    (A) an expression of dissatisfaction constituting an appeal under Insurance Code §4201.351; or

    (B) a misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or by clearing up the misunderstanding to the satisfaction of the complaining party.

  (7) Concurrent utilization review--A form of utilization review for ongoing health care or for an extension of treatment beyond previously approved health care.

  (8) Declination--A response to a request for verification in which an HMO or preferred provider benefit plan does not issue a verification for proposed medical care or health care services. A declination is not necessarily a determination that a claim resulting from the proposed services will not ultimately be paid.

  (9) Disqualifying association--Any association that may reasonably be perceived as having potential to influence the conduct or decision of a reviewing physician, doctor, or other health care provider, which may include:

    (A) shared investment or ownership interest;

    (B) contracts or agreements that provide incentives, for example, referral fees, payments based on volume or value, or waiver of beneficiary coinsurance and deductible amounts;

    (C) contracts or agreements for space or equipment rentals, personnel services, management contracts, referral services, warranties, or any other services related to the management of a physician's, doctor's, or other health care provider's practice;

    (D) personal or family relationships; or

    (E) any other financial arrangement that would require disclosure under the Insurance Code or applicable TDI rules, or any other association with the enrollee, employer, insurance carrier, or HMO that may give the appearance of preventing the reviewing physician, doctor, or other health care provider from rendering an unbiased opinion.

  (10) Doctor--A doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice.

  (11) Experimental or investigational--A health care treatment, service, or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device, but that is not yet broadly accepted as the prevailing standard of care.

  (12) Health care facility--A hospital, emergency clinic, outpatient clinic, or other facility providing health care.

  (13) Health coverage--Payment for health care services provided under a health benefit plan or a health insurance policy.

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

  (15) Insurance carrier or insurer--An entity authorized and admitted to do the business of insurance in Texas under a certificate of authority issued by TDI.

  (16) Independent review organization or IRO--As defined in §12.5 of this title (relating to Definitions).

  (17) Legal holiday--

    (A) a holiday as provided in Government Code §662.003(a);

    (B) the Friday after Thanksgiving Day;

    (C) December 24; and

    (D) December 26.

  (18) Medical records--The history of diagnosis and treatment, including medical, mental health records as allowed by law, dental, and other health care records from all disciplines providing care to an enrollee.

  (19) Mental health medical record summary--A summary of process or progress notes relevant to understanding the enrollee's need for treatment of a mental or emotional condition or disorder, including:

    (A) identifying information; and

    (B) a treatment plan that includes a:

      (i) diagnosis;

      (ii) treatment intervention;

      (iii) general characterization of enrollee behaviors or thought processes that affect level of care needs; and

      (iv) discharge plan.

  (20) Mental health therapist--Any of the following individuals who, in the ordinary course of business or professional practice, as appropriate, diagnose, evaluate, or treat any mental or emotional condition or disorder:

    (A) an individual licensed by the Texas Medical Board to practice medicine in this state;

    (B) an individual licensed as a psychologist, a psychological associate, or a specialist in school psychology by the Texas State Board of Examiners of Psychologists;

    (C) an individual licensed as a marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists;

    (D) an individual licensed as a professional counselor by the Texas State Board of Examiners of Professional Counselors;

    (E) an individual licensed as a social worker by the Texas State Board of Social Worker Examiners;

    (F) an individual licensed as a physician assistant by the Texas Medical Board;

    (G) an individual licensed as a registered professional nurse by the Texas Board of Nursing; or

    (H) any other individual who is licensed or certified by a state licensing board in the State of Texas, as appropriate, to diagnose, evaluate, or treat any mental or emotional condition or disorder.

  (21) Mental or emotional condition or disorder--A mental or emotional illness as detailed in the most current Diagnostic and Statistical Manual of Mental Disorders.

  (22) Person--Any individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, mental retardation center, mental health and mental retardation center, limited liability company, limited liability partnership, the statewide rural health care system under Insurance Code Chapter 845, and any similar entity.

  (23) Preauthorization--A form of prospective utilization review by a payor or its URA of health care services proposed to be provided to an enrollee.

  (24) Preferred provider--

    (A) with regard to a preferred provider benefit plan, a preferred provider as defined in Insurance Code Chapter 1301.

    (B) with regard to an HMO:

      (i) a physician, as defined in Insurance Code §843.002(22), who is a member of that HMO's delivery network; or

      (ii) a provider, as defined in Insurance Code §843.002(24), who is a member of that HMO's delivery network.

  (25) Provider of record--The physician, doctor, or other health care provider that has primary responsibility for the health care services rendered or requested on behalf of the enrollee or the physician, doctor, or other health care provider that has rendered or has been requested to provide the health care services to the enrollee. This definition includes any health care facility where health care services are rendered on an inpatient or outpatient basis.


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