2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9083 - Definitions

For purposes of this chapter:
(a) Qualified claim auditor.— Means a person employed or hired by a health insurance organization or issuer that is recognized as competent to perform or coordinate claim audits and that abides by policies and procedures geared to protect the confidentiality and properly manage all patient information in his/her possession.
(b) Claim audit.— Means a process to determine whether data in a claimant’s clinical record documents healthcare services listed on a claim for payment submitted to a health insurance organization or issuer. Claim audit does not mean a review of the medical necessity of the services provided, or the reasonableness of charges for the services.
(c) Overcharges or unsupported charges.— Means the volume of services indicated on a claim exceeds the total volume identified in the provider’s medical documentation.
(d) Unbilled charges.— Means charges or services provided for and not billed.
(e) Underbilled charges.— Means the volume of services indicated on a claim is less than the volume identified in the provider’s documentation.
(f) Ambulatory surgical center.— Means an establishment with an organized medical staff of physicians, with permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures. Such centers provide continuous physician services and registered nursing services whenever a patient is in the center. An ambulatory surgical center does not provide services for patients to stay overnight, but provide the following services whenever a patient is in the center:
(1) Drug services as needed for medical operations performed;
(2) provisions for physical and emotional well-being of patients;
(3) emergency services;
(4) administrative structure, and
(5) administrative, statistical, and medical records.
(g) Clinical record.— Means a longitudinal and chronological compilation composed of the demographic information and physical and/or behavioral mental health of the patient, family health history, if required and/or provided by the patient, which is completed, documented and kept under the custody of the healthcare service provider, and originated and registered electronically, on paper, or both. A patient’s clinical record includes, but is not limited to medical history, diagnoses, prescription drug history, allergy, notes on progress written by the healthcare provider, treatments, results of diagnostic tests ordered (clinical laboratory tests, x-rays, nuclear medicine tests, imaging, ultrasounds, among others) and may include dental impressions. The term clinical record shall be applied to the record generated on the course of providing healthcare services by a provider, and is subject to the protection of privacy, confidentiality, and security of federal and state regulations. This term shall also include the medical record.
(h) Provider.— Means healthcare professional or healthcare facility duly authorized to render or provide healthcare services.
(i) Final claim.— Means the final itemized bill from a provider detailing all the charges for which the provider is seeking payment.
(j) Claimant.— Means a covered person or enrollee under a health plan who has received healthcare services, the costs of which are submitted to a health insurance organization or issuer for payment, either by the claimant or by another on the claimant’s behalf.
History —Aug. 29, 2011, No. 194, § 6.030, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 5, eff. 30 days after July 10, 2013.