P.R. Laws tit. 24, § 7002
For the purposes of this chapter, the following terms and phrases shall have the meaning set forth below:
(a) Administration.— Puerto Rico Health Insurance Administration.
(b) Beneficiary alliances.— Groups of beneficiaries represented by the Administration in the negotiation of the health plan coverage benefits they need. These groups are composed of the beneficiaries of the Department of Health, or other groups that may avail themselves of the activities of the Administration in the future.
(c) Employer contribution.— Portion of the cost of the premium paid by the employer of the beneficiary.
(d) Personal contribution.— Portion of the cost of the premium paid by the beneficiary.
(e) Insurer.— The entity that assumes the contractual risk by being a paid a premium, duly-authorized by the Insurance Commissioner to do business in Puerto Rico; or the entity on which the Administration delegates through a contract the adjudication of the processing of the payment for services, in contracts between the Administration and participating purveyors.
(f) Internal fiscal audit.— The procedure established by the Administration to compile the information needed to corroborate that the services rendered to the beneficiaries were provided on the basis criteria of necessity and the same were billed correctly.
(g) Medicare beneficiary.— A person eligible for the Federal Medicare Program who also meets the requirements to be a beneficiary of the Administration.
(h) Co-insurance.— Percentage-based share of the beneficiary for each loss or portion of the cost of receiving a service.
(i) Commissioner.— Insurance Commissioner of Puerto Rico.
(j) Health benefit coverage.— All benefits for the beneficiaries included in a health plan.
(k) Department.— Department of Health of the Commonwealth of Puerto Rico.
(l) Executive Director.— The Executive Director of the Puerto Rico Health Insurance Administration.
(m) Emergency.— Refers to a medical condition this manifested by sufficiently severe, acute symptoms, including severe pain, which a reasonable prudent layperson, having average knowledge of medicine and health, may expect that the lack of immediate medical assistance could place the health of the person in grave danger, or would result in a serious dysfunction of any organ or member of the body; or with regard to pregnant women having contractions, the lack of sufficient time to transfer her to other facilities before the delivery, or that her transfer would represent a threat to the health of the woman or the unborn baby.
(n) Entity.— Any organization with its own legal status, organized or authorized to do business under the laws of Puerto Rico.
(o) Health facilities.— Those defined in §§ 331 et seq. of this title.
(p) Primary medical group.— Profitable or non-profitable entity that groups or associates primary physicians.
(q) Supporting medical group.— Either a profitable or non-profitable entity which groups or associates supporting physicians.
(r) Group of primary purveyors.— A profitable or non-profitable entity which groups or associates primary purveyors.
(s) Board of Directors.— Board of Directors of the Puerto Rico Health Insurance Administration.
(t) Act.— Puerto Rico Health Insurance Administration Act.
(u) Supporting physician.— The participating professional, purveyor who provides complementary and support services to primary physicians. In order to obtain these benefits, the beneficiary must be referred by the primary physician. The following are considered to be support[ing] physicians: cardiologists, endocrinologists, neurologists, psychiatrists, ophthalmologists, radiologists, nephrologists, physiotherapists, orthopedists, general surgeons and other physicians not included in the definition of primary physician.
(v) Primary physician.— The participating professional purveyor who evaluates and initially treats the beneficiaries. He/she is responsible for determining the services needed by the beneficiary [to] provide continuity, and to refer the beneficiaries for special services. The following are considered to be primary physicians: internists, family doctors, pediatricians, gynecologists and obstetricians.
(w) Health services organizations.— Groups of primary physicians, medical support groups, and primary care providers who meet the contracting requirements established by the Administration to offer health services through the managed care model. Health services organizations, as this term is defined in §§ 1901 et seq. of Title 26, known as the “Health Services Organizations Act”, incorporated into the Insurance Code of Puerto Rico, are also included in this definition.
(x) Capitation.— The part of the premium paid to the insurer that is transferred to the purveyor in payment of the benefits provided under health benefit coverage’s to the beneficiary represented by the Administration or such fixed payment made by the Administration to the participating purveyor for each beneficiary.
(y) Health plan.— Any contract through which a person is committed to provide to a beneficiary or group of beneficiaries, specific healthcare services, whether directly or through a healthcare provider, or to pay all or part of the cost of said services, in consideration of the payment of an amount prefixed in said contract, which is considered to be due regardless of whether or not the beneficiary uses the healthcare services provided by the plan. Notwithstanding the foregoing, said plan shall provide mainly for the rendering of healthcare services, as opposed to a mere indemnification for the cost of such services.
(z) Preauthorization.— A written authorization of the insurer to the beneficiary granting authorization to obtain a benefit. The beneficiary shall be responsible for obtaining such pre-authorization from the insurer in order to obtain the benefits it requires. Failure to obtain the pre-authorization when required shall prevent the beneficiary from obtaining the benefit, and the granting of the preauthorization binds the issuer to pay the service thus authorized.
(aa) Premium.— Remuneration granted to an insurer for assuming a risk through an insurance contract.
(bb) Basic premium.— The lowest premium from among all those contracted with the insurers.
(cc) Health services purveyor.— Shall consist of primary physicians, support physicians, primary services, primary purveyors and health service organizations.
(dd) Participating purveyor.— A health service purveyor contracted by the insurers by or [sic] the Administration to provide health services to the population represented by the Administration.
(ee) Primary purveyors.— Shall consist of participating purveyors that are clinical laboratories, radiology facilities pharmacies and hospitals, without including emergency rooms.
(ff) Referral.— Written authorization issued by the selected primary physician that allows the beneficiary to receive a service from another participating purveyor within a specific period of time.
(gg) Secretary.— Secretary of the Department of Health.
(hh) Primary services.— The emergency rooms of the participating purveyors.
History —Sept. 7, 1993, No. 72, Art. III; Dec. 29, 2000, No. 463, § 1; July 19, 2002, No. 105, § 2; Aug. 8, 2010, No. 123, § 2.