35 Pa. Stat. § 449.3
The following words and phrases when used in this act shall have the meanings given to them in this section unless the context clearly indicates otherwise:
"Allowance." The maximum allowed combined payment from a payor and a patient to a provider for services rendered.
"Ambulatory service facility." A facility licensed in this Commonwealth, not part of a hospital, which provides medical, diagnostic or surgical treatment to patients not requiring hospitalization, including ambulatory surgical facilities, ambulatory imaging or diagnostic centers, birthing centers, freestanding emergency rooms and any other facilities providing ambulatory care which charge a separate facility charge. This term does not include the offices of private physicians or dentists, whether for individual or group practices.
"Charge" or "rate." The amount billed by a provider for specific goods or services provided to a patient, prior to any adjustment for contractual allowances.
"Committee." The Health Care Cost Containment Council Act Review Committee.
"Council." The Health Care Cost Containment Council.
"Covered services." Any health care services or procedures connected with episodes of illness that require either inpatient hospital care or major ambulatory service such as surgical, medical or major radiological procedures, including any initial and follow-up outpatient services associated with the episode of illness before, during or after inpatient hospital care or major ambulatory service. The term does not include routine outpatient services connected with episodes of illness that do not require hospitalization or major ambulatory service.
"Data source." A health care facility; ambulatory service facility; physician; health maintenance organization as defined in the act of December 29, 1972 (P.L. 1701, No. 364), known as the Health Maintenance Organization Act; hospital, medical or health service plan with a certificate of authority issued by the Insurance Department, including, but not limited to, hospital plan corporations as defined in 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) and professional health services plan corporations as defined in 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations); commercial insurer with a certificate of authority issued by the Insurance Department providing health or accident insurance; self-insured employer providing health or accident coverage or benefits for employees employed in the Commonwealth; administrator of a self-insured or partially self-insured health or accident plan providing covered services in the Commonwealth; any health and welfare fund that provides health or accident benefits or insurance pertaining to covered service in the Commonwealth; the Department of Public Welfare for those covered services it purchases or provides through the medical assistance program under the act of June 13, 1967 (P.L. 31, No. 21), known as the Public Welfare Code, and any other payor for covered services in the Commonwealth other than an individual.
"Health care facility." A general or special hospital, including psychiatric hospitals, kidney disease treatment centers, including freestanding hemodialysis units, and ambulatory service facilities as defined in this section, and hospices, both profit and nonprofit, and including those operated by an agency of State or local government.
"Health care insurer." Any person, corporation or other entity that offers administrative, indemnity or payment services for health care in exchange for a premium or service charge under a program of health care benefits, including, but not limited to, an insurance company, association or exchange issuing health insurance policies in this Commonwealth; hospital plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations); professional health services plan corporation as defined in 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations); health maintenance organization; preferred provider organization; fraternal benefit societies; beneficial societies; and third-party administrators; but excluding employers, labor unions or health and welfare funds jointly or separately administered by employers or labor unions that purchase or self-fund a program of health care benefits for their employees or members and their dependents.
"Health maintenance organization." An organized system which combines the delivery and financing of health care and which provides basic health services to voluntarily enrolled subscribers for a fixed prepaid fee, as defined in the act of December 29, 1972 (P.L. 1701, No. 364), known as the Health Maintenance Organization Act.
"Hospital." An institution, licensed in this Commonwealth, which is a general, mental, chronic disease or other type of hospital, or kidney disease treatment center, whether profit or nonprofit, and including those operated by an agency of State or local government.
"Indigent care." The actual costs, as determined by the council, for the provision of appropriate health care, on an inpatient or outpatient basis, given to individuals who cannot pay for their care because they are above the medical assistance eligibility levels and have no health insurance or other financial resources which can cover their health care.
"Major ambulatory service." Surgical or medical procedures, including diagnostic and therapeutic radiological procedures, commonly performed in hospitals or ambulatory service facilities, which are not of a type commonly performed or which cannot be safely performed in physicians' offices and which require special facilities such as operating rooms or suites or special equipment such as fluoroscopic equipment or computed tomographic scanners, or a postprocedure recovery room or short-term convalescent room.
"Medical procedure incidence variations." The variation in the incidence in the population of specific medical, surgical and radiological procedures in any given year, expressed as a deviation from the norm, as these terms are defined in the classical statistical definition of "variation," "incidence," "deviation" and "norm."
"Medically indigent" or "indigent." The status of a person as described in the definition of indigent care.
"Payment." The payments that providers actually accept for their services, exclusive of charity care, rather than the charges they bill.
"Payor." Any person or entity, including, but not limited to, health care insurers and purchasers, that make direct payments to providers for covered services.
"Physician." An individual licensed under the laws of this Commonwealth to practice medicine and surgery within the scope of the act of October 5, 1978 (P.L. 1109, No. 261), known as the Osteopathic Medical Practice Act, or theact of December 20, 1985 (P.L. 457, No. 112) , known as the Medical Practice Act of 1985.
"Preferred provider organization." Any arrangement between a health care insurer and providers of health care services which specifies rates of payment to such providers which differ from their usual and customary charges to the general public and which encourage enrollees to receive health services from such providers.
"Provider." A hospital, an ambulatory service facility or a physician.
"Provider quality." The extent to which a provider renders care that, within the capabilities of modern medicine, obtains for patients medically acceptable health outcomes and prognoses, adjusted for patient severity, and treats patients compassionately and responsively.
"Provider service effectiveness." The effectiveness of services rendered by a provider, determined by measurement of the medical outcome of patients grouped by severity receiving those services.
"Purchaser." All corporations, labor organizations and other entities that purchase benefits which provide covered services for their employees or members, either through a health care insurer or by means of a self-funded program of benefits, and a certified bargaining representative that represents a group or groups of employees for whom employers purchase a program of benefits which provide covered services, but excluding entities defined in this section as "health care insurers."
"Raw data" or "data." Data collected by the council under section 6 . No data shall be released by the council except as provided for in section 11.
"Severity." In any patient, the measureable degree of the potential for failure of one or more vital organs.
35 P.S. § 449.3