SECTION 13.402. Definitions

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

(1) Affiliate--As defined in Insurance Code §848.001(1).

(2) Clinical director--Health professional who is:

(A) appropriately licensed in good standing in Texas;

(B) an employee of, or party to a contract with, an HCC; and

(C) responsible for clinical oversight of the utilization review program, the credentialing of professional staff, and quality improvement functions.

(3) Common service--An identical or substantially similar health care service provided to patients by two or more independent HCC participants.

(4) Confidential information--Information that relates to bidding, pricing, trade secrets, business planning documents, financial position and related operational results, profit and loss statements, contracts, salaries, employee benefits, or other competitively sensitive information.

(5) Credentialing--The periodic process of collecting, assessing, and validating qualifications and other relevant information pertaining to a physician or health care provider to determine eligibility to deliver health care services.

(6) Entity--An artificial person, including a partnership, association, organization, trust, or corporation; the term does not include a securities broker performing no more than the usual and customary broker's function.

(7) Facility--

(A) an ambulatory surgical center licensed under Health and Safety Code Chapter 243;

(B) a birthing center licensed under Health and Safety Code Chapter 244; or

(C) a hospital licensed under Health and Safety Code Chapter 241 or 577.

(8) Financial statement--An HCC's annual statement of financial position and operating results, including a balance sheet, receipts, and disbursements, certified by an independent certified public accountant and prepared in accord with Generally Accepted Accounting Principles.

(9) Health care collaborative or HCC--As defined in Insurance Code §848.001(2).

(10) Health care provider--As defined in Insurance Code §848.001(4).

(11) Health care services--As defined in Insurance Code §848.001(3).

(12) Health maintenance organization or HMO--As defined in Insurance Code §848.001(5).

(13) Hospital--As defined in Insurance Code §848.001(6).

(14) Individual--A natural person.

(15) Individual health care provider--A health care provider who is a natural person.

(16) Network--A health care delivery system in which an HCC provides or arranges to provide health care services directly or through contracts and subcontracts with governmental entities or private individuals or entities.

(17) Participant--Each physician or health care provider that has agreed to participate in the HCC.

(18) Patient--An individual who receives a health care service.

(19) Physician--As defined in Insurance Code §848.001(8).

(20) Primary service area or PSA--For each common service and each participant, the area defined by the smallest number of postal ZIP codes from which the participant draws at least 75 percent of its patients for that service.

(21) Private payor--Any of the following:

(A) an insurer that writes health insurance policies;

(B) an HMO, to the extent that it pays physicians or health care providers for health care services under an HMO evidence of coverage or under a negotiated-rate contract with the physician or health care provider; or

(C) any other entity, including an insurer or third-party administrator for self-insured private or governmental employers, that provides, or offers to provide, health care services to a patient pursuant to a negotiated-rate contract that the entity negotiated with physicians or health care providers.

(22) Pro-competitive benefit--A benefit obtained from clinical or financial integration by the establishment and operation of the HCC that ultimately accrues to the benefit of the HCC's patients. A pro-competitive benefit may include use of electronic medical records, implementation of quality control procedures, utilization review, clinical protocols, coordination of care, and financial incentives to reduce costs or increase quality.

(23) Quality improvement or QI--A system to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.

(24) Rural hospital--A hospital:

(A) that is paid under the Medicare hospital inpatient prospective payment system and is either located more than 35 miles from other like hospitals or is located in a rural area, and meets the criteria for sole community hospital status as specified by 42 CFR §412.92; or

(B) located in a rural area and that has been certified as a Medicare critical access hospital based on the criteria set forth in 42 CFR Part 485, Subpart F.

(25) Service area--A geographic area within which health care services are available and accessible to an HCC's patients who live, reside, or work within that geographic area and that complies with §13.473 of this title (relating to Organization of an HCC).

(26) Utilization review--As defined in Insurance Code §4201.002.

Source Note: The provisions of this §13.402 adopted to be effective March 31, 2013, 38 TexReg 2100