§ 23-17.13-2 Definitions.
As used in this chapter:
(1) "Adverse decision" means any decision by a review agent not to certify an admission, service, procedure, or extension of stay. A decision by a reviewing agent to certify an admission, service, or procedure in an alternative treatment setting, or to certify a modified extension of stay, shall not constitute an adverse decision if the reviewing agent and the requesting provider are in agreement regarding the decision.
(2) "Contractor" means a person/entity that:
(i) Establishes, operates or maintains a network of participating providers;
(ii) Contracts with an insurance company, a hospital or medical or dental service plan, an employer, whether under written or self insured, an employee organization, or any other entity providing coverage for health care services to administer a plan; and/or
(iii) Conducts or arranges for utilization review activities pursuant to chapter 17.12 of this title.
(3) "Direct service ratio" means the amount of premium dollars expended by the plan for covered services provided to enrollees on a plan's fiscal year basis.
(4) "Director" means the director of the department of health.
(5) "Emergency services" has the same meaning as the meaning contained in the rules and regulations promulgated pursuant to chapter 12.3 of title 42, as may be amended from time to time, and includes the sudden onset of a medical or mental condition that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction 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 care entity as described in subdivision (6) that provides for the delivery of care services to persons enrolled in the plan through:
(i) Arrangements with selected providers to furnish health care services; and/or
(ii) Financial incentives for persons enrolled in the plan to use 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 provider of health care services or supplies, and whose services are recognized pursuant to 213(d) of the Internal Revenue Code, 26 U.S.C. § 213(d), that has entered into an agreement with a health care entity as described in subdivision (6) or contractor as described in subdivision (2) to provide these services or supplies to a patient enrolled in a plan.
(10) "Provider incentive plan" means any compensation arrangement between a health care entity or plan and a provider or provider group that may directly or indirectly have the effect of reducing or limiting services provided with respect to an individual enrolled in a plan.
(11) "Qualified health plan" means a plan that the director of the department of health certified, upon application by the program, as meeting the requirements of this chapter.
(12) "Qualified utilization review program" means utilization review program that meets the requirements of chapter 17.12 of this title.
(13) "Most favored rate clause" means a provision in a provider contract whereby the rates or fees to be paid by a health plan are fixed, established or adjusted to be equal to or lower than the rates or fees paid to the provider by any other health plan or third party payor.
(P.L. 1996, ch. 41, § 1; P.L. 2003, ch. 214, § 1.)