2023 Maryland Statutes › Insurance › Title 14 - Entities That Act as Health Insurers › Subtitle 2 - Preferred Provider Organizations › Section 14-201 - Definitions

(a)    In this subtitle the following words have the meanings indicated.
(b)    “Allowed amount” means the dollar amount that an insurer determines is the value of the health care service provided by a provider before any cost sharing amounts are applied.
(c)    “Assignment of benefits” means the transfer of health care coverage reimbursement benefits or other rights under a preferred provider insurance policy by an insured.
(d)    “Balance bill” means the difference between a nonpreferred provider’s bill for a health care service and the insurer’s allowed amount.
(e)    “Cost sharing amounts” means the amounts that an insured is responsible for under a preferred provider insurance policy, including any deductibles, coinsurance, or copayments.
(f)    “Covered service” means a health care service that is a covered benefit under a preferred provider insurance policy.
(g)    “Health care services” has the meaning stated in § 19–701 of the Health – General Article.
(h)    “Hospital–based physician” means:
(1)    a physician licensed in the State who is under contract to provide health care services to patients at a hospital; or
(2)    a group physician practice that includes physicians licensed in the State that is under contract to provide health care services to patients at a hospital.
(i)    “Insured” means a person covered for benefits under a preferred provider insurance policy offered or administered by an insurer.
(j)    “Medicare economic index” means the fixed–weight input price index that:
(1)    measures the weighted average annual price change for various inputs needed to produce physician services; and
(2)    is used by the Centers for Medicare and Medicaid Services in the calculation of reimbursement of physician services under Title XVIII of the federal Social Security Act.
(k)    “Nonpreferred provider” means a provider that is eligible for payment under a preferred provider insurance policy, but that is not a preferred provider under the applicable provider service contract.
(l)    “On–call physician” means a physician who:
(1)    has privileges at a hospital;
(2)    is required to respond within an agreed upon time period to provide health care services for unassigned patients at the request of a hospital or a hospital emergency department; and
(3)    is not a hospital–based physician.
(m)    “Preferential basis” means an arrangement under which the insured or subscriber under a preferred provider insurance policy is entitled to receive health care services from preferred providers at no cost, at a reduced fee, or under more favorable terms than if the insured or subscriber received similar services from a nonpreferred provider.
(n)    “Preferred provider” means a provider that has entered into a provider service contract.
(o)    “Preferred provider insurance policy” means:
(1)    a policy or insurance contract that is issued or delivered in the State by an insurer, under which health care services are to be provided to the insured by a preferred provider on a preferential basis; or
(2)    another contract that is offered by an employer, third party administrator, or other entity, under which health care services are to be provided to the subscriber by a preferred provider on a preferential basis.
(p)    “Provider” means a physician, hospital, or other person that is licensed or otherwise authorized to provide health care services.
(q)    “Provider service contract” means a contract between a provider and an insurer, employer, third party administrator, or other entity, under which the provider agrees to provide health care services on a preferential basis under specific preferred provider insurance policies.
(r)    “Similarly licensed provider” means:
(1)    for a physician:
(i)    a physician who is board certified or eligible in the same practice specialty; or
(ii)    a group physician practice that contains board certified or eligible physicians in the same practice specialty; or
(2)    for a health care provider who is not a physician, a health care provider who holds the same type of license or certification.
(s)    “Subscriber” means a person covered for benefits under a preferred provider insurance policy issued by a person that is not an insurer.