Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 405 - RULES GOVERNING BALANCE BILLING FOR OUT-OF-NETWORK HEALTH CARE SERVICES › Section 14VAC5-405-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter shall
				  have the following meanings, unless the context clearly indicates
				  otherwise:
"Allowed amount" means the maximum portion of a billed charge
				  a health carrier will pay, including any applicable cost-sharing requirements,
				  for a covered service or item rendered by a participating provider or by a
				  nonparticipating provider.
"Arbitrator" means an individual included on a list of
				  arbitrators approved by the commission pursuant to 14VAC5-405-50.
"Balance bill" means a bill sent to an enrollee by an
				  out-of-network provider for health care services provided to the enrollee after
				  the provider's billed amount is not fully reimbursed by the carrier, exclusive
				  of applicable cost-sharing requirements.
"Child" means a son, daughter, stepchild, adopted child,
				  including a child placed for adoption, foster child, or any other child
				  eligible for coverage under the health benefit plan.
"Clean claim" means a claim (i) that has no material defect
				  or impropriety, including any lack of any reasonably required substantiation
				  documentation, that substantially prevents timely payment from being made on
				  the claim; and (ii) that includes required Internal Revenue Service
				  documentation for the carrier to process payment. A carrier shall notify the
				  person submitting the claim of any defect or impropriety.
"Commercially reasonable payment" or "commercially
				  reasonable amount" means payments or amounts a carrier is required to reimburse
				  a health care provider for out-of-network services pursuant to §§
									38.2-3445.01
				  and
				  38.2-3445.02
				  of the Code of Virginia.
"Commission" means the State Corporation Commission.
"Cost-sharing requirement" means an enrollee's deductible,
				  copayment amount, or coinsurance rate. "Covered benefits" or "benefits" means
				  those health care services to which an individual is entitled under the terms
				  of a health benefit plan.
"Dependent" means the spouse or child of an eligible
				  employee, subject to the applicable terms of the policy, contract, or plan
				  covering the eligible employee.
"Elective group health plan" means
(i)  a self-funded group
				  health plan providing or administering an employee welfare benefit plan as
				  defined in § 3(1) of ERISA,
				  29
				  USC §
										1002(1), that is
				  self-insured or self-funded with respect to such plan and that establishes for
				  its enrollees a network of participating providers, or a self-funded group
				  health plan for local government employees, local officers, teachers, and
				  retirees, and the dependents of such employees, officers, teachers, and
				  retirees; and (ii) elects to participate in the requirements of §§
									38.2-3445
				  through
				  38.2-3445.07
				  of the Code of Virginia by notifying the commission in accordance with
				  14VAC5-405-80.
"Emergency medical condition" means, regardless of the final
				  diagnosis rendered to an enrollee, a medical condition manifesting itself by
				  acute symptoms of sufficient severity, including severe pain, so that a prudent
				  layperson, who possesses an average knowledge of health and medicine, could
				  reasonably expect the absence of immediate medical attention to result in (i)
				  serious jeopardy to the mental or physical health of the individual, (ii)
				  danger of serious impairment to bodily functions, (iii) serious dysfunction of
				  any bodily organ or part, or (iv) in the case of a pregnant woman, serious
				  jeopardy to the health of the fetus.
"Emergency services" means with respect to an emergency
				  medical condition (i) a medical screening examination as required under §
				  1867 of the Social Security Act (
				  42
				  USC §
										1395dd ) that is within the
				  capability of the emergency department of a hospital, including ancillary
				  services routinely available to the emergency department to evaluate such
				  emergency medical condition and (ii) such further medical examination and
				  treatment, to the extent they are within the capabilities of the staff and
				  facilities available at the hospital, as are required under § 1867 of the
				  Social Security Act (
				  42
				  USC §
										1395dd(e)(3) ) to
				  stabilize the patient.
"Enrollee" means a policyholder, subscriber, covered person,
				  participant, or other individual covered by a health benefit plan. "ERISA"
				  means the Employee Retirement Income Security Act of 1974 (
				  29 USC §
										1001 et seq.).
"Facility" means an institution providing health care related
				  services or a health care setting, including hospitals and other licensed
				  inpatient centers; ambulatory surgical or treatment centers; skilled nursing
				  centers; residential treatment centers; diagnostic, laboratory, and imaging
				  centers; and rehabilitation and other therapeutic health settings.
"Health benefit plan" means a policy, contract, certificate,
				  or agreement offered by a health carrier to provide, deliver, arrange for, pay
				  for, or reimburse any of the costs of health care services.
"Health benefit plan" includes short-term and catastrophic
				  health insurance policies, and a policy that pays on a cost-incurred basis,
				  except as otherwise specifically exempted in this definition.
"Health benefit plan" also includes an elective group health
				  plan.
"Health benefit plan" does not include the "excepted
				  benefits" as defined in §
									38.2-3431
				  of the Code of Virginia.
"Health care professional" means a physician or other health
				  care practitioner licensed, accredited, or certified to perform specified
				  health care services consistent with state law.
"Health care provider" or "provider" means a health care
				  professional or facility.
"Health care services" means services for the diagnosis,
				  prevention, treatment, cure, or relief of a health condition, illness, injury,
				  or disease.
"Health carrier" means an entity subject to the insurance
				  laws and regulations of the Commonwealth and subject to the jurisdiction of the
				  commission that contracts or offers to contract to provide, deliver, arrange
				  for, pay for, or reimburse any of the costs of health care services, including
				  an insurer licensed to sell accident and sickness insurance, a health
				  maintenance organization, a health services plan, or any other entity providing
				  a plan of health insurance, health benefits, or health care services.
"Initiating party" means the health carrier or out-of-network
				  provider that requests arbitration pursuant to §
									38.2-3445.02
				  of the Code of Virginia and 14VAC5-405-40.
"In-network" or "participating" means a provider that has
				  contracted with a carrier or a carrier's contractor or subcontractor to provide
				  health care services to enrollees and be reimbursed by the carrier at a
				  contracted rate as payment in full for the health care services, including
				  applicable cost-sharing requirements.
"Managed care plan" means a health benefit plan that either
				  requires an enrollee to use, or creates incentives, including financial
				  incentives, for an enrollee to use health care providers managed, owned, under
				  contract with, or employed by the health carrier.
"Network" means the group of participating providing services
				  to a managed care plan.
"Offer to pay" or "payment notification" means a claim that
				  has been adjudicated and paid by a carrier or determined by a carrier to be
				  payable by an enrollee to an out-of-network provider for services described in
				  subsection A of §
									38.2-3445.01
				  of the Code of Virginia.
"Out-of-network" or "nonparticipating" means a provider that
				  has not contracted with a carrier or a carrier's contractor or subcontractor to
				  provide health care services to enrollees.
"Out-of-pocket maximum" or "maximum out-of-pocket" means the
				  maximum amount an enrollee is required to pay in the form of cost-sharing
				  requirements for covered benefits in a plan year, after which the carrier
				  covers the entirety of the allowed amount of covered benefits under the
				  contract of coverage.
"Provider group" means a group of multispecialty or single
				  specialty health care professionals who contract with a facility to exclusively
				  provide multispecialty or single specialty health care services at the
				  facility.
"Receipt" means five calendar days after mailing or the date
				  of electronic transmittal.
"Surgical or ancillary services" means any professional
				  services, including surgery, anesthesiology, pathology, radiology, or
				  hospitalist services and laboratory services.
"Written" or "in writing" means a written communication that
				  is electronically transmitted. Paper communication is discouraged.
Statutory Authority: 12.1-13 and 38.2-223 of the Code of
					 Virginia.