SECTION 21.2421. Definitions - Division 2

Definitions for Division 2. For purposes of Division 2 of this subchapter, the following terms have the meanings indicated, except where the context clearly indicates otherwise:

(1) Emergency care--A health care service or benefit:

(A) provided in an air, land, or water ambulance, and that is emergency care as defined under Insurance Code Chapter 1201; or

(B) that meets a plan's applicable statutory definition of emergency care in Insurance Code Chapters 843, 1201, or 1301, or emergency care as required in Insurance Code §1271.155, provided in a hospital emergency facility, licensed freestanding emergency medical care facility, community mental health center, or comparable emergency facility.

(2) In-network--Care covered under the plan's in-network benefit, including care provided by:

(A) an in-network provider; or

(B) an out-of-network provider as required by Insurance Code Chapters 1271 and 1301, and §3.3708 (relating to Payment of Certain Basic Benefit Claims and Related Disclosures), §3.3725 (relating to Payment of Certain Out-of-Network Claims) of this title, and §11.1611 (relating to Out-of-Network Claims; Non-Network Physicians and Providers) of this title.

(3) Inpatient--Care provided on an inpatient basis. Inpatient health care services or benefits are provided in an inpatient facility, including, but not limited to, those identified in CMS Form 1500 POS Codes 21 (Inpatient Hospital (other than psychiatric)), 31 (Skilled Nursing Facility), 32 (Nursing Facility), 34 (Hospice), 51 (Inpatient Psychiatric Facility), 54 (Intermediate Care Facility/Individuals with Intellectual Disabilities), 55 (Residential Substance Abuse Treatment Facility), 56 (Psychiatric Residential Treatment Center), and 61 (Comprehensive Inpatient Rehabilitation Facility).

(4) Office visit--A medical/surgical or mental health/substance use disorder (MH/SUD) service or benefit received in an office, including, but not limited to, those identified in CMS Form 1500 POS Code 11 (Office).

(5) Outpatient--Care provided on an outpatient basis. Outpatient health care services or benefits are provided in an outpatient setting other than an office visit, including, but not limited to, those identified in CMS Form 1500 POS Codes 17 (Walk-in Retail Health Clinic), 18 (Place of Employment/Worksite), 19 (Off Campus - Outpatient Hospital), 20 (Urgent Care Facility), 22 (On Campus - Outpatient Hospital), 24 (Ambulatory Surgical Center), 49 (Independent Clinic), 52 (Psychiatric Facility - Partial Hospitalization), 53 (Community Mental Health Center), 57 (Non-residential Substance Abuse Treatment Facility), 62 (Comprehensive Outpatient Rehabilitation Facility), 65 (End-Stage Renal Disease Treatment Facility), and 72 (Rural Health Clinic).

(6) Out-of-network--Care covered under the plan's out-of-network benefit, and all care under an indemnity plan or other health benefit plan that has no network of providers. Care provided by an out-of-network provider that is covered under the plan's in-network benefit is not out-of-network care.

Source Note: The provisions of this §21.2421 adopted to be effective September 7, 2021, 46 TexReg 5571