Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS
Subchapter A - GENERAL PROVISIONS AND DEFINITIONS
Section 10.2 - Definitions
Universal Citation: 28 TX Admin Code § 10.2
Current through Reg. 50, No. 13; March 28, 2025
(a) The following words and terms when used in this chapter have the following meanings unless the context clearly indicates otherwise.
(1) Administrator--Has
the meaning assigned by Insurance Code §
4151.001, concerning
Definitions.
(2) Adverse
determination--A determination by a URA made on behalf of a payor that the
health care services provided or proposed to be provided to an injured employee
are not medically necessary or appropriate. The term does not include a denial
of health care services due to the failure to request prospective or concurrent
utilization review. For the purposes of this subchapter, an adverse
determination does not include a determination that health care services are
experimental or investigational.
(3) Affiliate--Has the meaning assigned by
Insurance Code §
1305.004, concerning
Definitions.
(4) Capitation--Has
the meaning assigned by Insurance Code §
1305.004. The term
includes predetermined payment to cover the average costs of services for a
defined episode of care.
(5)
Complainant--Has the meaning assigned by Insurance Code §
1305.004.
(6) Complaint--Has the meaning assigned by
Insurance Code §
1305.004.
(7) Concurrent utilization review--A form of
utilization review for ongoing health care or for an extension of treatment
beyond previously approved health care.
(8) Credentialing--Has the meaning assigned
by Insurance Code §
1305.004.
(9) Division of Workers' Compensation--Has
the meaning assigned to the "Division" by Labor Code §
401.011, concerning
General Definitions.
(10)
Emergency--Has the meaning assigned by Insurance Code §
1305.004.
(11) Employee--Has the meaning assigned by
Labor Code §
401.012, concerning
Definition of Employee.
(12) Fee
dispute--Has the meaning assigned by Insurance Code §
1305.004.
(13) HMO--A health maintenance organization
licensed and regulated under Insurance Code Chapter 843, concerning Health
Maintenance Organizations.
(14)
Independent review--Has the meaning assigned by Insurance Code §
1305.004.
(15) Independent review organization--Has the
meaning assigned by Insurance Code §
1305.004.
(16) Life-threatening--Has the meaning
assigned by Insurance Code Chapter 4201, concerning Utilization Review
Agents.
(17) Live or lives--Where
an employee lives includes:
(A) the employee's
principal residence for legal purposes, including the physical address that the
employee represented to the employer as the employee's address;
(B) a temporary residence necessitated by
employment; or
(C) a temporary
residence taken by the employee primarily for the purpose of receiving
necessary assistance with routine daily activities because of a compensable
injury.
(18) MCQA--The
Office of Managed Care Quality Assurance, or a successor office at the
department.
(19) Medical
emergency--Has the meaning assigned by Insurance Code §
1305.004.
(20) Medical records--Has the meaning
assigned by Insurance Code §
1305.004.
(21) Mental health emergency--Has the meaning
assigned by Insurance Code §
1305.004.
(22) Network or workers' compensation health
care network--Has the meaning assigned by Insurance Code §
1305.004.
(23) Occupational medicine specialist--A
doctor who has received a board certification in occupational medicine from the
American Board of Preventive Medicine or who has completed all the requirements
of the American Board of Preventive Medicine in order to take the board
examination.
(24) Person--Has the
meaning assigned by Insurance Code §
1305.004.
(25) Physician--Has the meaning assigned by
Insurance Code §
4201.002, concerning
Definitions.
(26)
Preauthorization--A form of prospective utilization review by a payor or a
payor's URA of health care services proposed to be provided to an injured
employee.
(27) Provider--A health
care provider.
(28) Quality
improvement program--Has the meaning assigned by Insurance Code §
1305.004.
(29) Retrospective review--A form of
utilization review for health care services that have been provided to an
injured employee. Retrospective review does not include review of services for
which prospective or concurrent utilization reviews were previously conducted
or should have been previously conducted.
(30) Routine daily activities-Activities a
person normally does in daily living, including sleeping, eating, bathing,
dressing, grooming, and homemaking.
(31) Rural area--Has the meaning assigned by
Insurance Code §
1305.004.
(32) Screening criteria--Has the meaning
assigned by Insurance Code §
1305.004.
(33) Service area--Has the meaning assigned
by Insurance Code §
1305.004.
(34) Telehealth service, telemedicine medical
service, and teledentistry dental service--Have the meanings assigned by
Occupations Code §
111.001, concerning
Definitions.
(35) Transfer of
risk--Has the meaning assigned by Insurance Code §
1305.004.
(36) Utilization review--Has the meaning
assigned by Insurance Code Chapter 4201.
(37) Utilization review agent or URA--Has the
meaning assigned by Insurance Code Chapter 4201.
(b) When used in this chapter, the following terms have the meanings assigned by Labor Code § 401.011:
(1) administrative violation;
(2) case management;
(3) compensable injury;
(4) doctor;
(5) employer;
(6) evidence-based medicine;
(7) health care;
(8) health care facility;
(9) health care practitioner;
(10) health care provider;
(11) impairment rating;
(12) injury;
(13) insurance carrier;
(14) maximum medical improvement;
and
(15) treating doctor.
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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