2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter A. General Provisions › Section 4201.002. Definitions

Sec. 4201.002.  DEFINITIONS.  In this chapter:
(1)  "Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or are experimental or investigational.
(2)  "Emergency care" means health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual's condition, sickness, or injury is of such a nature that failure to get immediate medical care could:
(A)  place the individual's health in serious jeopardy;
(B)  result in serious impairment to bodily functions;
(C)  result in serious dysfunction of a bodily organ or part;
(D)  result in serious disfigurement; or
(E)  for a pregnant woman, result in serious jeopardy to the health of the fetus.
(3)  "Enrollee"  means an individual covered by a health insurance policy or health benefit plan.  The term includes an individual who is covered as an eligible dependent of another individual.
(4)  "Health benefit plan" means a plan of benefits, other than a health insurance policy, that:
(A)  defines the coverage provisions for health care for enrollees; and
(B)  is offered or provided by a public or private organization.
(5)  "Health care provider" means a person, corporation, facility, or institution that is:
(A)  licensed by a state to provide or is otherwise lawfully providing health care services; and
(B)  eligible for independent reimbursement for those health care services.
(6)  "Health insurance policy" means an insurance policy, including a policy written by a corporation subject to Chapter 842, that provides coverage for medical or surgical expenses incurred as a result of accident or sickness.
(7)  "Life-threatening" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(8)  "Nurse" means a professional or registered nurse, a licensed vocational nurse, or a licensed practical nurse.
(9)  "Patient" means the enrollee or an eligible dependent of the enrollee under a health benefit plan or health insurance policy.
(10)  "Payor" means:
(A)  an insurer that writes health insurance policies;
(B)  a preferred provider organization, health maintenance organization, or self-insurance plan; or
(C)  any other person or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to a person treated by a health care provider in this state under a policy, plan, or contract.
(11)  "Physician" means a licensed doctor of medicine or a doctor of osteopathy.
(12)  "Provider of record" means the physician or other health care provider with primary responsibility for the health care services provided to or requested on behalf of an enrollee or the physician or other health care provider that has provided or has been requested to provide the health care services to the enrollee. The term includes a health care facility where the health care services are provided on an inpatient or outpatient basis.
(13)  "Utilization review" includes a system for prospective, concurrent, or retrospective review of the medical necessity and appropriateness of health care services and a system for prospective, concurrent, or retrospective review to determine the experimental or investigational nature of health care services.  The term does not include a review in response to an elective request for clarification of coverage.
(14)  "Utilization review agent" means an entity that conducts utilization review for:
(A)  an employer with employees in this state who are covered under a health benefit plan or health insurance policy;
(B)  a payor; or
(C)  an administrator holding a certificate of authority under Chapter 4151.
(15)  "Utilization review plan" means the screening criteria and utilization review procedures of a utilization review agent.
(16)  "Working day" means a weekday that is not a legal holiday.
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 7, eff. September 1, 2009.
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.01, eff. September 1, 2019.