SECTION 187.87. Definitions

The following words and terms when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.

(1) Board--Texas Medical Board.

(2) Enrollee--An individual who is eligible to receive benefits through a preferred provider benefit plan offered by an insurer under the Insurance Code, Chapter 1301 or a health benefit plan, other than an HMO plan, under the Texas Insurance Code, Chapter 1551.

(3) Facility--a hospital, emergency clinic, outpatient clinic, birthing center, ambulatory surgical center, or other facility providing health care services.

(4) Facility-based physician--a radiologist, an anesthesiologist, a pathologist, an emergency department physician; a neonatologist; or an assistant surgeon:

(A) to whom the facility has granted clinical privileges; and

(B) who provides services to patients of the facility pursuant to those clinical privileges.

(5) Mediation--a process in which an impartial mediator facilitates and promotes agreement between the insurer offering a preferred provider benefit plan or the administrator and a facility-based physician or the physician's representative to settle a health benefit claim of an enrollee pursuant to Chapter 1467 of the Texas Insurance Code.

(6) Mediator--an impartial person who is appointed by the chief administrative law judge at the State Office of Administrative Hearings to conduct a mediation, pursuant to Chapter 1467 of the Texas Insurance Code.

(7) Out-of-network health benefit claim--A claim for payment for medical or health care services that are furnished by a physician that is not contracted as a preferred provider with a preferred provider benefit plan or contracted with an administrator.

(8) Qualified health benefit claim--A health benefit claim that meets all of the criteria under 28 TAC §21.5010(a) and (b) (relating to Qualified Claim Criteria).

Source Note: The provisions of this §187.87 adopted to be effective May 2, 2010, 35 TexReg 3279; amended to be effective February 21, 2016, 41 TexReg 1119