Iowa Administrative Code › Agency 191 - Insurance Division › Property and Casualty Insurance › Chapter 27 - Preferred Provider Arrangements › Rule 191-27.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter, unless the context otherwise
				  requires:
"Commissioner"
means the commissioner of
				  insurance.
"Coveredperson"
means a person on whose
				  behalf the health care insurer is obligated to pay for or provide health care
				  services.
"Covered services"
means health care
				  services which the health care insurer is obligated to pay for or provide under
				  the health benefit plan.
"Emergency services"
means, with respect to
				  an individual enrolled with an organization, covered inpatient and outpatient
				  services that are furnished by a provider that is qualified to furnish such
				  services and are needed to evaluate or stabilize an emergency medical
				  condition. The term "emergency medical condition" means a medical condition
				  manifesting itself by acute symptoms of sufficient severity, including severe
				  pain, that a prudent layperson, who possesses an average knowledge of health
				  and medicine, could reasonably expect that absence of immediate medical
				  attention to result in one of the following:
1. Placing the health of the individual or,
				with respect to a pregnant woman, the health of the woman and her unborn child,
				in serious jeopardy;
2. Serious
				impairment to bodily function; or
3. Serious dysfunction of any bodily organ or
				part.
"Health benefit plan"
means the health
				  insurance policy or subscriber agreement between the covered person or the
				  policyholder and the health care insurer which defines the covered services and
				  benefit levels available.
"Health care insurer"
means a third-party
				  payer of health benefits including, but not limited to, a person providing a
				  policy or contract providing for third-party payment or prepayment of health or
				  medical expenses, including the following:
1. Individual or group accident and sickness
				insurance providing coverage on an expense-incurred basis.
2. An individual or group hospital or medical
				service contract issued pursuant to Iowa Code chapter 509, 514 or
				514A.
3. An individual or group
				health maintenance organization contract regulated under Iowa Code chapter
				514B.
4. An individual or group
				Medicare supplement policy.
5. A
				fraternal benefit society.
"Health care provider"
or
"provider"
means a provider of health care services as
				  defined in rule
				  191-342.
				  (514).
"Health care services"
means services
				  rendered or products sold by a health care provider within the scope of the
				  provider's license. The term includes, but is not limited to, hospital,
				  medical, surgical, dental, vision, and pharmaceutical services or
				  products.
"Preferredprovider"
means a health care
				  provider or group of providers who have contracted to provide specified covered
				  services.
"Preferred provider arrangement"
means a
				  contract between or on behalf of the health care insurer and a preferred
				  provider which complies with all the requirements of this
				  chapter