§ 23-17.13-2 - Definitions.
SECTION 23-17.13-2
§ 23-17.13-2 Definitions. – As used in this chapter:
(1) "Adverse decision" means any decision by a review agentnot to certify an admission, service, procedure, or extension of stay. Adecision by a reviewing agent to certify an admission, service, or procedure inan alternative treatment setting, or to certify a modified extension of stay,shall not constitute an adverse decision if the reviewing agent and therequesting provider are in agreement regarding the decision.
(2) "Contractor" means a person/entity that:
(i) Establishes, operates or maintains a network ofparticipating providers;
(ii) Contracts with an insurance company, a hospital ormedical or dental service plan, an employer, whether under written or selfinsured, an employee organization, or any other entity providing coverage forhealth care services to administer a plan; and/or
(iii) Conducts or arranges for utilization review activitiespursuant to chapter 17.12 of this title.
(3) "Direct service ratio" means the amount of premiumdollars expended by the plan for covered services provided to enrollees on aplan's fiscal year basis.
(4) "Director" means the director of the department of health.
(5) "Emergency services" has the same meaning as the meaningcontained in the rules and regulations promulgated pursuant to chapter 12.3 oftitle 42, as may be amended from time to time, and includes the sudden onset ofa medical or mental condition that the absence of immediate medical attentioncould reasonably be expected to result in placing the patient's health inserious jeopardy, serious impairment to bodily or mental functions, or seriousdysfunction of any bodily organ or part.
(6) "Health care entity" means a licensed insurance company,hospital, or dental or medical service plan or health maintenance organization,or a contractor as described in subdivision (2), that operates a health plan.
(7) "Health care services" includes, but is not limited to,medical, mental health, substance abuse, and dental services.
(8) "Health plan" means a plan operated by a health careentity as described in subdivision (6) that provides for the delivery of careservices to persons enrolled in the plan through:
(i) Arrangements with selected providers to furnish healthcare services; and/or
(ii) Financial incentives for persons enrolled in the plan touse the participating providers and procedures provided for by the plan.
(9) "Provider" means a physician, hospital, pharmacy,laboratory, dentist, or other state licensed or other state recognized providerof health care services or supplies, and whose services are recognized pursuantto 213(d) of the Internal Revenue Code, 26 U.S.C. § 213(d), that hasentered into an agreement with a health care entity as described in subdivision(6) or contractor as described in subdivision (2) to provide these services orsupplies to a patient enrolled in a plan.
(10) "Provider incentive plan" means any compensationarrangement between a health care entity or plan and a provider or providergroup that may directly or indirectly have the effect of reducing or limitingservices provided with respect to an individual enrolled in a plan.
(11) "Qualified health plan" means a plan that the directorof the department of health certified, upon application by the program, asmeeting the requirements of this chapter.
(12) "Qualified utilization review program" means utilizationreview program that meets the requirements of chapter 17.12 of this title.
(13) "Most favored rate clause" means a provision in aprovider contract whereby the rates or fees to be paid by a health plan arefixed, established or adjusted to be equal to or lower than the rates or feespaid to the provider by any other health plan or third party payor.