SECTION 3.9202. Definitions

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

(1) Adverse determination--A determination by a utilization review agent that the health care services furnished or proposed to be furnished to a patient are not medically necessary or not appropriate.

(2) Complaint--Any dissatisfaction, expressed by a complainant orally or in writing to the issuer, with any aspect of the issuer's operation, including plan administration; the denial, or termination of a service for reasons not related to medical necessity; the way a service is provided; or disenrollment decisions, expressed by a complainant. The term does not include a misunderstanding or problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the insured and does not include a provider's or insured's oral or written dissatisfaction with an adverse determination.

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

(4) Emergency care--Health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

(A) placing the patient's health in serious jeopardy;

(B) serious impairment to bodily functions;

(C) serious dysfunction of any bodily organ or part;

(D) serious disfigurement; or

(E) in the case of a pregnant woman, serious jeopardy to the health of the fetus.

(5) Exclusive provider--A health care provider or an organization of health care providers who contract or subcontract to provide health care services to covered persons.

(6) Exclusive provider benefit plan (EPP)--A type of health care plan offered by an issuer that arranges for or provides benefits to covered persons through a network of exclusive providers, and that limits or excludes benefits for services provided by other providers, except in cases of emergency or approved referral.

(7) Health care provider--Any person, corporation, facility, or institution licensed by the State of Texas (including physicians and practitioners listed in Insurance Code Chapter 1451) to provide health care services.

(8) Health care services--Any episodic or ongoing services such as pharmaceutical, diagnostic, behavioral health, medical, dental care, or chiropractic in either an inpatient or outpatient setting rendered by a health care provider for the purpose of treating, preventing, alleviating, curing, or healing illness, injury, or disease.

(9) Hospital--A licensed public or private institution as defined in Chapter 241, Health and Safety Code, or in Subtitle C, Title 7, Health and Safety Code.

(10) Independent review organization--An entity that is certified by the commissioner to conduct independent review under the authority of Insurance Code Chapter 4202.

(11) Institutional provider--A hospital, nursing home, or any other medical or health-related service facility caring for the sick or injured or providing care for other coverage which may be provided in a health insurance policy.

(12) Insured--For purposes of this subchapter, a person covered under an EPP.

(13) Issuer--An insurance company authorized to do business in Texas that contracts with the Health and Human Services Commission (HHSC) to provide CHIP or Medicaid coverage or contracts with or is sponsored by the System to issue an exclusive provider benefit plan.

(14) Life-threatening--A disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

(15) Limited provider network--A subnetwork within a network in which contractual relationships exist between health care providers, physician associations and/or physician groups which limit the insureds' access to only those health care providers in the subnetwork.

(16) Out-of-area benefits--Benefits that the EPP covers when its insureds are outside the geographical limits of the EPP service area.

(17) Physician--Anyone licensed to practice medicine in the State of Texas.

(18) Primary care physician or primary care provider--A health care provider who has been selected by the insured to provide initial and primary care, maintain the continuity of patient care, and who may initiate referrals for care.

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

(20) Service area--A defined geographic area within which health care services are available and accessible to EPP insureds who live, reside, or work within that geographic area.

(21) Urgent care--Health care services provided in a situation other than an emergency which are typically provided in settings such as a health care 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 his or her 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 current health condition.

(22) Utilization review--A system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual within this state. Utilization review will not include elective requests for clarification of coverage.

Source Note: The provisions of this §3.9202 adopted to be effective September 17, 2003, 28 TexReg 7993; amended to be effective May 11, 2022, 47 TexReg 2758