2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.001. Definitions

Sec. 1467.001.  DEFINITIONS.  In this chapter:
(1)  "Administrator" means:
(A)  an administering firm for a health benefit plan providing coverage under Chapter 1551, 1575, or 1579; and
(B)  if applicable, the claims administrator for the health benefit plan.
(1-a)  "Arbitration" means a process in which an impartial arbiter issues a binding determination in a dispute between a health benefit plan issuer or administrator and an out-of-network provider or the provider's representative to settle a health benefit claim.
(2)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(2), eff. September 1, 2019.
(2-a)  "Diagnostic imaging provider" means a health care provider who performs a diagnostic imaging service on a patient for a fee or interprets imaging produced by a diagnostic imaging service.
(2-b)  "Diagnostic imaging service" means magnetic resonance imaging, computed tomography, positron emission tomography, or any hybrid technology that combines any of those imaging modalities.
(2-c)  "Emergency care" has the meaning assigned by Section 1301.155.
(2-d)  "Emergency care provider" means a physician, health care practitioner, facility, or other health care provider who provides and bills an enrollee, administrator, or health benefit plan for emergency care.
(3)  "Enrollee" means an individual who is eligible to receive benefits through a health benefit plan subject to this chapter.
(3-a)  "Facility" has the meaning assigned by Section 324.001, Health and Safety Code.
(4)  "Facility-based provider" means a physician, health care practitioner, or other health care provider who provides health care or medical services to patients of a facility.
(4-a)  "Health care practitioner" means an individual who is licensed to provide health care services.
(4-b)  "Laboratory service provider" means an accredited facility in which a specimen taken from a human body is interpreted and pathological diagnoses are made or a physician who makes an interpretation of or diagnosis based on a specimen or information provided by a laboratory based on a specimen.
(5)  "Mediation" means a process in which an impartial mediator facilitates and promotes agreement between the health benefit plan issuer or the administrator and an out-of-network provider or the provider's representative to settle a health benefit claim of an enrollee.
(6)  "Mediator" means an impartial person who is appointed to conduct a mediation under this chapter.
(6-a)  "Out-of-network provider" means a diagnostic imaging provider, emergency care provider, facility-based provider, or laboratory service provider that is not a participating provider for a health benefit plan.
(7)  "Party" means a health benefit plan issuer offering a health benefit plan, an administrator, or an out-of-network provider or the provider's representative who participates in a mediation or arbitration conducted under this chapter.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 467 (S.B. 481), Sec. 4, eff. September 1, 2015.
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 1, eff. September 1, 2017.
Acts 2017, 85th Leg., R.S., Ch. 139 (H.B. 1428), Sec. 1, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.01, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(2), eff. September 1, 2019.