Texas Administrative Code
Title 22 - EXAMINING BOARDS
Part 9 - TEXAS MEDICAL BOARD
Chapter 187 - PROCEDURAL RULES
Subchapter J - PROCEDURES RELATED TO OUT-OF-NETWORK HEALTH BENEFIT CLAIM DISPUTE RESOLUTION
Section 187.87 - Definitions

Universal Citation: 22 TX Admin Code ยง 187.87

Current through Reg. 49, No. 38; September 20, 2024

The following words and terms when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.

(1) Board--Texas Medical Board.

(2) Enrollee--An individual who is eligible to receive benefits through a preferred provider benefit plan offered by an insurer under the Insurance Code, Chapter 1301 or a health benefit plan, other than an HMO plan, under the Texas Insurance Code, Chapter 1551.

(3) Facility--a hospital, emergency clinic, outpatient clinic, birthing center, ambulatory surgical center, or other facility providing health care services.

(4) Facility-based physician--a radiologist, an anesthesiologist, a pathologist, an emergency department physician; a neonatologist; or an assistant surgeon:

(A) to whom the facility has granted clinical privileges; and

(B) who provides services to patients of the facility pursuant to those clinical privileges.

(5) Mediation--a process in which an impartial mediator facilitates and promotes agreement between the insurer offering a preferred provider benefit plan or the administrator and a facility-based physician or the physician's representative to settle a health benefit claim of an enrollee pursuant to Chapter 1467 of the Texas Insurance Code.

(6) Mediator--an impartial person who is appointed by the chief administrative law judge at the State Office of Administrative Hearings to conduct a mediation, pursuant to Chapter 1467 of the Texas Insurance Code.

(7) Out-of-network health benefit claim--A claim for payment for medical or health care services that are furnished by a physician that is not contracted as a preferred provider with a preferred provider benefit plan or contracted with an administrator.

(8) Qualified health benefit claim--A health benefit claim that meets all of the criteria under 28 TAC § 21.5010(a) and (b) (relating to Qualified Claim Criteria).

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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