§ 27-20.10-1. Definitions.
For purposes of this chapter, the following definitions shall apply:
(1) “Contracting entity” means any person or entity that enters into direct contracts with providers for the delivery of healthcare services in the ordinary course of business.
(2) “Control” and “under common control with” shall mean possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of an entity through the ownership of fifty percent (50%) or more of the voting securities of the entity.
(3) “Covered individual” means an individual who is covered under a health insurance plan.
(4) “Department” means the department of business regulation.
(5) “Direct notification” is a written or electronic communication from a contracting entity to a provider documenting a third-party access to a provider network.
(6) “Healthcare services” means services for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.
(7)(i) “Health insurance plan” means any hospital and medical expense incurred policy, nonprofit healthcare service plan contract, health maintenance organization subscriber contract, or any other healthcare plan or arrangement that pays for or furnishes medical or healthcare services, whether by insurance or otherwise.
(ii) “Health insurance plan” shall not include one or more, or any combination of, the following: coverage only for accident, or disability income insurance; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; coverage similar to the foregoing as specified in federal regulation issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; dental or vision benefits; benefits for long-term care, nursing home care, home health care, or community-based care; specified disease or illness coverage, hospital indemnity or other fixed indemnity insurance, or such other similar, limited benefits as are specified in regulations; Medicare supplemental health insurance as defined under § 1882(g)(1) of the Social Security Act [42 U.S.C. § 1395ss]; coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; or other similar limited benefit supplemental coverages.
(8)(i) “Provider” means a physician, a physician organization, or a physician hospital organization that is acting exclusively as an administrator on behalf of a provider to facilitate the provider’s participation in healthcare contracts.
(ii) “Provider” does not include a physician organization or physician hospital organization that leases or rents the physician organization’s or physician hospital organization’s network to a third party.
(9) “Provider network contract” means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of and payment for healthcare services to covered individuals.
(10) “Third party” means an organization that enters into a contract with a contracting entity or with another third party to gain access to a provider network contract.
History of Section.
P.L. 2009, ch. 190, § 1; P.L. 2009, ch. 209, § 1.