Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PRELIMINARY PROVISIONS › Section 69.3 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
						have the following meanings, unless the context clearly indicates
						otherwise:
Act 6
-The act of February 7, 1990 (P. L.
						11, No. 6).
Burn facility
-A facility which meets the
						service standards of the American Burn Association.
Care
or
services
-The
						treatment, accommodations, products or services provided by a person or
						institution.
Carrier
-An organization with a
						contractual relationship with HCFA to process Medicare Part B claims.
Commissioner
-The Insurance Commissioner
						of the Commonwealth.
DRG
-Diagnostic-related group.
Department
-The Insurance Department of
						the Commonwealth.
HCFA
-The Health Care Financing
						Administration.
Insured
-An injured person covered by an
						automobile insurance policy issued under the MVFRL.
Insurer
-A property and casualty
						insurance company providing coverage under automobile insurance policies to
						residents of this Commonwealth.
Intermediary
-An organization with a
						contractual relationship with HCFA to process Medicare Part A claims.
Life-threatening injury
-The term shall
						be as defined by the American College of Surgeons' triage guidelines regarding
						the use of trauma centers for the region where the services are
						provided.
MVFRL-Motor Vehicle Financial Responsibility
						Law
-Title 75 of the
Pennsylvania Consolidated
						Statutes
§§ 1701-1799.7 (relating to the Motor Vehicle
						Financial Responsibility Law).
Medicare Part A
-Medicare hospital
						insurance benefits which reimburse providers for facility-based care, such as
						in-patient and out-patient hospital services and skilled nursing care.
Medicare Part B
-Medicare supplementary
						medical insurance which reimburses providers for physician services, durable
						medical equipment, physical therapy and other services.
Medicare payment
-Payment at 110% of the
						Medicare reimbursement allowance which includes the prevailing charge at the
						75th percentile; the applicable fee schedule, the recommended fee or the
						inflation index charge; the DRG payment; or any other Medicare reimbursement
						mechanism; as applied in this Commonwealth under the Medicare Program.
Medicare prevailing charge
-The lowest
						customary charge high enough to include 75% of the individual provider charges
						for services as adjusted by all limitations mandated by HCFA and the
						carrier.
Medicare recommended fee
-The fee for
						which a Medicare payment schedule does not exist, and which is developed based
						upon a solicited recommendation from a consulting specialist or group of
						specialists. This fee may vary depending upon the specifics of a particular
						case.
PRO-Peer Review Organization
-A
						professional organization with which HCFA or the Commonwealth contracts for
						medical review of Medicare or Medical Assistance services, or a health care
						entity approved by the Commissioner, that engages in reviewing medical files
						for the purpose of determining that medical and rehabilitation services are
						medically necessary and economically provided.
Pass-through costs
-Medicare reimbursed
						costs to a hospital that "pass through" the prospective payment system and are
						not included in the DRG payments. The term includes medical education, capital
						expenditures, insurance and interest expense on fixed assets.
Provider
-A person or institution which
						provides treatment, accommodations, products or services.
Trauma center
-A facility accredited by
						the Pennsylvania Trauma Systems Foundation under the Emergency Medical Services
						Act (35 P. S. §§
												6921-6938).
Urgent injury
-The term shall be as
						defined by the American College of Surgeons' triage guidelines regarding use of
						trauma centers for the region where the services are provided.
Usual and customary charge
-The charge
						most often made by providers of similar training, experience and licensure for
						a specific treatment, accommodation, product or service in the geographic area
						where the treatment, accommodation, product or service is
						provided.