| (a) Words and terms defined in Insurance Code Chapter
1301, concerning Preferred Provider Benefit Plans, 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), concerning Definitions.
(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),
concerning Definitions.
(8) Facility-based physician or provider--As defined
in Insurance Code §1451.501, concerning Definitions.
(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), concerning Definitions.
(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) SERFF--The National Association of Insurance Commissioners
(NAIC) System for Electronic Rates & Forms Filing.
(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).
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| 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; amended to be effective April 25, 2024, 49 TexReg 2497 |
