This is a clone of the Texas Administrative Code (TAC) for educational purposes. It is not the official version and should not be used for legal purposes. Site created Wed, 21 May 2025 21:16:48 GMT
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,