Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter A - GENERAL PROVISIONS AND DEFINITIONS › Section 10.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(a) The following words and terms when used
				  in this chapter have the following meanings unless the context clearly
				  indicates otherwise.
(1) Administrator--Has
				  the meaning assigned by Insurance Code §
											4151.001, concerning
				  Definitions.
(2) Adverse
				  determination--A determination by a URA made on behalf of a payor that the
				  health care services provided or proposed to be provided to an injured employee
				  are not medically necessary or appropriate. The term does not include a denial
				  of health care services due to the failure to request prospective or concurrent
				  utilization review. For the purposes of this subchapter, an adverse
				  determination does not include a determination that health care services are
				  experimental or investigational.
(3) Affiliate--Has the meaning assigned by
				  Insurance Code §
											1305.004, concerning
				  Definitions.
(4) Capitation--Has
				  the meaning assigned by Insurance Code §
											1305.004. The term
				  includes predetermined payment to cover the average costs of services for a
				  defined episode of care.
(5)
				  Complainant--Has the meaning assigned by Insurance Code §
											1305.004.
(6) Complaint--Has the meaning assigned by
				  Insurance Code §
											1305.004.
(7) Concurrent utilization review--A form of
				  utilization review for ongoing health care or for an extension of treatment
				  beyond previously approved health care.
(8) Credentialing--Has the meaning assigned
				  by Insurance Code §
											1305.004.
(9) Division of Workers' Compensation--Has
				  the meaning assigned to the "Division" by Labor Code §
											401.011,
				  concerning General Definitions.
(10) Emergency--Has the meaning assigned by
				  Insurance Code §
											1305.004.
(11) Employee--Has the meaning assigned by
				  Labor Code §
											401.012,
				  concerning Definition of Employee.
(12) Fee dispute--Has the meaning assigned by
				  Insurance Code §
											1305.004.
(13) HMO--A health maintenance organization
				  licensed and regulated under Insurance Code Chapter 843, concerning Health
				  Maintenance Organizations.
(14)
				  Independent review--Has the meaning assigned by Insurance Code §
											1305.004.
(15) Independent review organization--Has the
				  meaning assigned by Insurance Code §
											1305.004.
(16) Life-threatening--Has the meaning
				  assigned by Insurance Code Chapter 4201, concerning Utilization Review
				  Agents.
(17) Live or lives--Where
				  an employee lives includes:
(A) the employee's
				  principal residence for legal purposes, including the physical address that the
				  employee represented to the employer as the employee's address;
(B) a temporary residence necessitated by
				  employment; or
(C) a temporary
				  residence taken by the employee primarily for the purpose of receiving
				  necessary assistance with routine daily activities because of a compensable
				  injury.
(18) MCQA--The
				  Office of Managed Care Quality Assurance, or a successor office at the
				  department.
(19) Medical
				  emergency--Has the meaning assigned by Insurance Code §
											1305.004.
(20) Medical records--Has the meaning
				  assigned by Insurance Code §
											1305.004.
(21) Mental health emergency--Has the meaning
				  assigned by Insurance Code §
											1305.004.
(22) Network or workers' compensation health
				  care network--Has the meaning assigned by Insurance Code §
											1305.004.
(23) Occupational medicine specialist--A
				  doctor who has received a board certification in occupational medicine from the
				  American Board of Preventive Medicine or who has completed all the requirements
				  of the American Board of Preventive Medicine in order to take the board
				  examination.
(24) Person--Has the
				  meaning assigned by Insurance Code §
											1305.004.
(25) Physician--Has the meaning assigned by
				  Insurance Code §
											4201.002, concerning
				  Definitions.
(26)
				  Preauthorization--A form of prospective utilization review by a payor or a
				  payor's URA of health care services proposed to be provided to an injured
				  employee.
(27) Provider--A health
				  care provider.
(28) Quality
				  improvement program--Has the meaning assigned by Insurance Code §
											1305.004.
(29) Retrospective review--A form of
				  utilization review for health care services that have been provided to an
				  injured employee. Retrospective review does not include review of services for
				  which prospective or concurrent utilization reviews were previously conducted
				  or should have been previously conducted.
(30) Routine daily activities-Activities a
				  person normally does in daily living, including sleeping, eating, bathing,
				  dressing, grooming, and homemaking.
(31) Rural area--Has the meaning assigned by
				  Insurance Code §
											1305.004.
(32) Screening criteria--Has the meaning
				  assigned by Insurance Code §
											1305.004.
(33) Service area--Has the meaning assigned
				  by Insurance Code §
											1305.004.
(34) Telehealth service, telemedicine medical
				  service, and teledentistry dental service--Have the meanings assigned by
				  Occupations Code §
											111.001, concerning
				  Definitions.
(35) Transfer of
				  risk--Has the meaning assigned by Insurance Code §
											1305.004.
(36) Utilization review--Has the meaning
				  assigned by Insurance Code Chapter 4201.
(37) Utilization review agent or URA--Has the
				  meaning assigned by Insurance Code Chapter 4201.