Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 1 - GENERAL REQUIREMENTS › Section 3.3702 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(a) Words and terms defined in Insurance Code
					 Chapter 1301, concerning Preferred Provider Benefit Plans, have the same
					 meaning when used in this subchapter, unless the context clearly indicates
					 otherwise.
(b) The following words
					 and terms, when used in this subchapter, have the following meanings, unless
					 the context clearly indicates otherwise:
(1)
					 Adverse determination--As defined in Insurance Code §
												4201.002(1),
					 concerning Definitions.
(2) Allowed
					 amount--The amount of a billed charge that an insurer determines to be covered
					 for services provided by a nonpreferred provider. The allowed amount includes
					 both the insurer's payment and any applicable deductible, copayment, or
					 coinsurance amounts for which the insured is responsible.
(3) Billed charges--The charges for medical
					 care or health care services included on a claim submitted by a physician or
					 provider.
(4) Complainant--As
					 defined in §
												21.2502 of this title (relating to
					 Definitions).
(5) Complaint--As
					 defined in §
												21.2502 of this title.
(6) Contract holder--An individual who holds
					 an individual health insurance policy, or an organization that holds a group
					 health insurance policy.
(7)
					 Facility--As defined in Health and Safety Code §
												324.001(7),
					 concerning Definitions.
(8)
					 Facility-based physician or provider--As defined in Insurance Code §
												1451.501, concerning
					 Definitions.
(9) Health care
					 provider or provider--As defined in Insurance Code §
												1301.001
					 (1-a).
(10) Health maintenance
					 organization (HMO)--As defined in Insurance Code §
												843.002(14),
					 concerning Definitions.
(11)
					 In-network--Medical or health care treatment, services, or supplies furnished
					 by a preferred provider, or a claim filed by a preferred provider for the
					 treatment, services, or supplies.
(12) NCQA--The National Committee for Quality
					 Assurance, which reviews and accredits managed care plans.
(13) Nonpreferred provider--A physician or
					 health care provider, or an organization of physicians or health care
					 providers, that does not have a contract with the insurer to provide medical
					 care or health care on a preferred benefit basis to insureds covered by a
					 health insurance policy issued by the insurer.
(14) Out-of-network--Medical or health care
					 treatment services, or supplies furnished by a nonpreferred provider, or a
					 claim filed by a nonpreferred provider for the treatment, services, or
					 supplies.
(15) Pediatric
					 practitioner--A physician or provider with appropriate education, training, and
					 experience whose practice is limited to providing medical and health care
					 services to children and young adults.
(16) Provider network--The collective group
					 of physicians and health care providers available to an insured under a
					 preferred or exclusive provider benefit plan and directly or indirectly
					 contracted with the insurer of a preferred or exclusive provider benefit plan
					 to provide medical or health care services to individuals insured under the
					 plan.
(17) SERFF--The National
					 Association of Insurance Commissioners (NAIC) System for Electronic Rates &
					 Forms Filing.
(18) Urgent
					 care--Medical or health care services provided in a situation other than an
					 emergency that are typically provided in a setting such as a physician or
					 individual provider's office or urgent care center, as a result of an acute
					 injury or illness that is severe or painful enough to lead a prudent layperson,
					 possessing an average knowledge of medicine and health, to believe that the
					 person's condition, illness, or injury is of such a nature that failure to
					 obtain treatment within a reasonable period of time would result in serious
					 deterioration of the condition of the person's health.
(19) Utilization review--As defined in
					 Insurance Code §
												4201.002(13).