Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION › Section 21.4503 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this subchapter
					 have the following meanings unless the context clearly indicates
					 otherwise:
(1) Allowed amount--The
				  amount that the applicable health benefit plan issuer allows as payment for a
				  health care service or group of services, including amounts for which a patient
				  is responsible due to deductibles, copayments, or coinsurance.
(2) Ambulatory surgical center--A facility
				  licensed under Health and Safety Code Chapter 243.
(3) Applicable health benefit plan--A group
				  health benefit plan as specified in Insurance Code §
										38.352 and §
				  38.353, which is a preferred provider benefit plan as defined by Insurance Code
				  §
										1301.001, including
				  an exclusive provider benefit plan consistent with Insurance Code §
										1301.0042,
				  or an evidence of coverage for a health care plan that provides basic health
				  care services as defined by Insurance Code §
										843.002, or a state
				  employee health plan under Insurance Code Chapters 1551, 1575, 1579, and 1601.
				  The term does not include an HMO plan providing routine dental or vision
				  services as a single health care service plan or a preferred provider benefit
				  plan providing routine vision services as a single health care service
				  plan.
(4) Billed amount--The amount
				  charged for health care services on a claim submitted by a provider.
(5) Facility claims--Any claim for health
				  care services provided by a facility as defined in §
										3.3702 of
				  this title.
(6) Freestanding
				  emergency medical care facility--A freestanding emergency medical care facility
				  required to be licensed under Health and Safety Code Chapter 254.
(7) Geographic region--A three-digit ZIP code
				  representing the collection of ZIP codes that share the same first three
				  digits. For purposes of data submitted under this subchapter, a geographic
				  region must be located in Texas, in full or in part.
(8) Imaging claims--Claims for radiological
				  services furnished in a provider office, outpatient hospital, or other
				  outpatient environment.
(9)
				  Inpatient procedure claims--Claims for health care services furnished in a
				  hospital, as defined by Insurance Code §
										1301.001, to a
				  patient who is formally admitted.
(10) In-network claims--Claims filed with an
				  applicable health benefit plan for health care treatment, services, or supplies
				  furnished by a provider contracted as an in-network or preferred provider under
				  the plan.
(11) Medical billing
				  codes--Standard code sets used to bill for specific medical services, including
				  the Healthcare Common Procedure Coding System (HCPCS) and Diagnosis-Related
				  Group (DRG) system established by the Centers for Medicare and Medicaid
				  Services (CMS), the Current Procedural Terminology (CPT) code set maintained by
				  the American Medical Association, and the International Classification of
				  Diseases (ICD) code sets developed by the World Health Organization.
(12) Out-of-network claims--Claims filed with
				  an applicable health benefit plan for health care treatment, services, or
				  supplies furnished by a provider that is not an in-network provider or
				  preferred provider under the plan. Claims paid on an out-of-network basis are
				  considered out-of-network regardless of whether the provider is reimbursed
				  based on an agreed on rate.
(13)
				  Outpatient facility procedure claims--Claims for health care services furnished
				  in an ambulatory surgical center or a hospital, as defined by Insurance Code
				  §
										1301.001, to a
				  patient who is not formally admitted.
(14) Place-of-service code--A health care
				  claim code where "place of service" refers to the type of entity where services
				  were rendered, as specified by a two-digit place-of-service code on a
				  professional health care claim consistent with the ASC X12N standard for
				  electronic transactions. Place-of-service codes are maintained by
				  CMS.
(15) Primary plan--As defined
				  in paragraph (17) of this section.
(16) Professional claims--Any claim for
				  health care services provided by a physician or provider that is not an
				  institutional provider, as defined in Insurance Code §
										1301.001.
(17) Provider--Any physician, practitioner,
				  institutional provider, or other person or organization that furnishes health
				  care services and is licensed or otherwise authorized to practice in this
				  state.
(18) Reporting period--The
				  12-month interval of time for which a plan or applicable health benefit plan
				  issuer must submit data each year, beginning each January 1 and ending the
				  following December 31.
(19)
				  TDI--Texas Department of Insurance.