Section 21.5003 - DefinitionsThe following words and terms have the following meanings when used in this subchapter unless the context clearly indicates otherwise.
(1) Administrator--Has the meaning assigned by Insurance Code § 1467.001, concerning Definitions. The term also includes an administrator of a nonprofit agricultural organization under Insurance Code Chapter 1682, concerning Health Benefits Provided by Certain Nonprofit Agricultural Organizations, and an administrator of a self-insured or self-funded ERISA plan under Insurance Code Chapter 1275, concerning Balance Billing Prohibitions and Out-of-Network Claim Dispute Resolution for Certain Plans, offering a health benefit plan.(2) Arbitration--Has the meaning assigned by Insurance Code § 1467.001.(3) Claim--A request to a health benefit plan for payment for health benefits under the terms of the health benefit plan's coverage, including emergency care, or a health care or medical service or supply, or any combination of emergency care and health care or medical services and supplies, provided that the care, services, or supplies: (A) are furnished for a single date of service; or(B) if furnished for more than one date of service, are provided as a continuing or related course of treatment over a period of time for a specific medical problem or condition, or in response to the same initial patient complaint.(4) Diagnostic imaging provider--Has the meaning assigned by Insurance Code § 1467.001.(5) Diagnostic imaging service--Has the meaning assigned by Insurance Code § 1467.001.(6) Emergency care--Has the meaning assigned by Insurance Code § 1301.155, concerning Emergency Care.(7) Emergency care provider--Has the meaning assigned by Insurance Code § 1467.001.(8) ERISA--The Employee Retirement Income Security Act of 1974 (29 USC § 1001 et seq.).(9) Enrollee--Has the meaning assigned by Insurance Code § 1467.001.(10) Facility--Has the meaning assigned by Health and Safety Code § 324.001, concerning Definitions.(11) Health benefit plan--A plan that provides coverage under: (A) a health benefit plan offered by an HMO operating under Insurance Code Chapter 843, concerning Health Maintenance Organizations;(B) a preferred provider benefit plan, including an exclusive provider benefit plan, offered by an insurer under Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans;(C) a plan, other than an HMO plan, under Insurance Code Chapters 1551, concerning Texas Employees Group Benefits Act; 1575, concerning Texas Public School Employees Group Benefits Program; 1579, concerning Texas School Employees Uniform Group Health Coverage; or 1682; or(D) a self-insured or self-funded plan established by an employer under ERISA for which the plan sponsor has elected to apply Insurance Code Chapter 1275 to the plan for the relevant plan year.(12) Facility-based provider--Has the meaning assigned by Insurance Code § 1467.001.(13) Insurer--A life, health, and accident insurance company; health insurance company; or other company operating under: Insurance Code Chapters 841, concerning Life, Health, or Accident Insurance Companies; 842, concerning Group Hospital Service Corporations; 884, concerning Stipulated Premium Insurance Companies; 885, concerning Fraternal Benefit Societies; 982, concerning Foreign and Alien Insurance Companies; or 1501, concerning Health Insurance Portability and Availability Act, that is authorized to issue, deliver, or issue for delivery in this state a preferred provider benefit plan, including an exclusive provider benefit plan, under Insurance Code Chapter 1301.(14) Mediation--Has the meaning assigned by Insurance Code § 1467.001.(15) Mediator--Has the meaning assigned by Insurance Code § 1467.001.(16) Out-of-network claim--A claim for payment for medical or health care services or supplies or both furnished by an out-of-network provider or a non-network provider.(17) Out-of-network provider--Has the meaning assigned by Insurance Code § 1467.001.(18) Party--Has the meaning assigned by Insurance Code § 1467.001.28 Tex. Admin. Code § 21.5003
The provisions of this §21.5003 adopted to be effective October 19, 2010, 35 TexReg 9300; Amended by Texas Register, Volume 41, Number 44, October 28, 2016, TexReg 8615, eff. 11/3/2016; Amended by Texas Register, Volume 43, Number 16, April 20, 2018, TexReg 2427, eff. 4/26/2018; Amended by Texas Register, Volume 44, Number 51, December 20, 2019, TexReg 8014, eff. 12/23/2019; Amended by Texas Register, Volume 47, Number 07, February 18, 2022, TexReg 0793, eff. 2/20/2022; Amended by Texas Register, Volume 48, Number 52, December 29, 2023, TexReg 8378, eff. 1/3/2024