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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle D. PROVIDER PLANS |
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Chapter 1305. WORKERS' COMPENSATION HEALTH CARE NETWORKS |
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Subchapter A. GENERAL PROVISIONS |
Sec. 1305.004. DEFINITIONS
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(a) In this chapter, unless the context clearly indicates otherwise:
(1) "Adverse determination" has the meaning assigned by Chapter 4201.
(1-a) "Administrator" has the meaning assigned by Section 4151.001.
(2) "Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, the person specified.
(3) "Capitation" means a method of compensation for arranging for or providing health care services to employees for a specified period that is based on a predetermined payment for each employee for the specified period, without regard to the quantity of services provided for the compensable injury.
(4) "Complainant" means a person who files a complaint under this chapter. The term includes:
(A) an employee;
(B) an employer;
(C) a health care provider; and
(D) another person designated to act on behalf of an employee.
(5) "Complaint" means any dissatisfaction expressed orally or in writing by a complainant to a network regarding any aspect of the network's operation. The term includes dissatisfaction relating to medical fee disputes and the network's administration and the manner in which a service is provided. The term does not include:
(A) a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the complainant; or
(B) an oral or written expression of dissatisfaction or disagreement with an adverse determination.
(6) "Credentialing" means the review, under nationally recognized standards to the extent that those standards do not conflict with other laws of this state, of qualifications and other relevant information relating to a health care provider who seeks a contract with a network.
(7) "Emergency" means either a medical or mental health emergency.
(8) "Employee" has the meaning assigned by Section 401.012, Labor Code.
(9) "Fee dispute" means a dispute over the amount of payment due for health care services determined to be medically necessary and appropriate for treatment of a compensable injury.
(10) "Independent review" means a system for final administrative review by an independent review organization of the medical necessity and appropriateness, or the experimental or investigational nature, of health care services being provided, proposed to be provided, or that have been provided to an employee.
(11) "Independent review organization" means an entity that is certified by the commissioner to conduct independent review under Chapter 4202 and rules adopted by the commissioner.
(12) "Life-threatening" has the meaning assigned by Chapter 4201.
(13) "Medical emergency" means the sudden onset of a medical condition manifested by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in:
(A) placing the patient's health or bodily functions in serious jeopardy; or
(B) serious dysfunction of any body organ or part.
(14) "Medical records" means the history of diagnosis and treatment for an injury, including medical, dental, and other health care records from each health care practitioner who provides care to an injured employee.
(15) "Mental health emergency" means a condition that could reasonably be expected to present danger to the person experiencing the mental health condition or another person.
(16) "Network" or "workers' compensation health care network" means an organization that is:
(A) formed as a health care provider network to provide health care services to injured employees;
(B) certified in accordance with this chapter and commissioner rules; and
(C) established by, or operates under contract with, an insurance carrier.
(17) "Nurse" has the meaning assigned by Chapter 4201.
(18) "Person" means any natural or artificial person, including an individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, mental retardation center, mental health and mental retardation center, limited liability company, or limited liability partnership.
(19) "Preauthorization" means the process required to request approval from the insurance carrier or the network to provide a specific treatment or service before the treatment or service is provided.
(20) "Quality improvement program" means a system designed to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.
(21) Repealed by Acts 2009, 81st Leg., R.S., Ch. 1330, Sec. 19(1), eff. September 1, 2009.
(22) "Rural area" means:
(A) a county with a population of 50,000 or less;
(B) an area that is not designated as an urbanized area by the United States Census Bureau; or
(C) any other area designated as rural under rules adopted by the commissioner.
(23) "Screening criteria" means the written policies, medical protocols, and treatment guidelines used by an insurance carrier or a network as part of utilization review.
(24) "Service area" means a geographic area within which health care services from network providers are available and accessible to employees who live within that geographic area.
(25) "Texas Workers' Compensation Act" means Subtitle A, Title 5, Labor Code.
(26) "Transfer of risk" means, for purposes of this chapter only, an insurance carrier's transfer of financial risk for the provision of health care services to a network through capitation or other means.
(27) "Utilization review" has the meaning assigned by Chapter 4201.
(28) "Utilization review agent" has the meaning assigned by Chapter 4201.
(29) "Utilization review plan" means the screening criteria and utilization review procedures of an insurance carrier, a workers' compensation health care network, or a utilization review agent.
(b) In this chapter, the following terms have the meanings assigned by Section 401.011, Labor Code:
(1) "compensable injury";
(2) "doctor";
(3) "employer";
(4) "health care";
(5) "health care facility";
(6) "health care practitioner";
(7) "health care provider";
(8) "injury";
(9) "insurance carrier";
(10) "orthotic device";
(11) "prosthetic device"; and
(12) "treating doctor."