1. (a) The definitions of "person", "evidence of coverage", and of "insurance policy or insurance contract" contained in the Trade Practices Act, Arkansas Code § 23-66-203, and in Arkansas Code § 23-76-102 shall apply to this part.

2. (b) In addition, where used in this part:

   1. (1) "Agent" or "representative" means any individual, corporation, association, partnership, or other legal entity authorized to represent an insurer, health maintenance organization, or risk retention group with respect to a claim;
   2. (2) "Automobile insurance" includes, but is not limited to, insurance as defined under Arkansas Code § 23-89-301;

   3. (3) "Claimant" means an enrollee, a first-party claimant, and/or a third-party claimant, and includes:

      1. (A) Such claimant's designated legal representative; and
      2. (B) A member of the claimant's immediate family designated by the claimant;

   4. (4)

      1. (A) "Clean claim" means a claim for payment of healthcare expenses that is submitted on a HCFA 1500, on a UB92, in a format required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), or on the carrier's standard claim form with all required fields completed in accordance with the health carrier’s published claim filing requirements.
      2. (B) A clean claim shall not include a claim for:

3. (i) Payment of expenses incurred during a period of time for which premiums are delinquent;

   1. (ii) Benefits under a Medicare supplement policy if the claim is not accompanied by an explanation of Medicare benefits or the explanation of Medicare benefits (EOMB) has not been otherwise received by the health carrier; or

      1. (iii) Which the health carrier needs additional information in order to resolve one (1) or more of the issues listed in 23 CAR § 15-111(c);
   2. (5) "Complaint" means a written communication primarily expressing a grievance;
   3. (6) “Contracted provider” means a provider that contracts with a health carrier to provide services for "health insureds" of such carrier;
   4. (7) "First-party claimant" means an individual, corporation, association, partnership, or other legal entity asserting a right to payment or services under an insurance policy or contract, or health care plan arising out of the occurrence of the contingency, loss, injury, or illness covered by such policy, contract, or plan;

   5. (8)

      1. (A) “Health carrier” means a health maintenance organization, hospital medical service corporation, or a disability insurance company that issues health insurance contracts as defined in subdivision (12) of this section.

      2. (B) For purposes of this rule, unless otherwise stated, the term "health carrier" shall include a self-insured governmental or church plan, as well as third-party administrators that administer or adjust disability benefits for a:

         1. (i) Disability insurer;
         2. (ii) Hospital medical service corporation;
         3. (iii) Health maintenance organization;
         4. (iv) Self-insured governmental plan; or
         5. (v) Self-insured church plan.

      3. (C)

         1. (i) A health carrier does not include an automobile insurer paying medical or hospital benefits under Arkansas Code § 23-89-202(1) nor shall it include a self-insured employer health benefits plan.
         2. (ii) A health carrier also does not include any person, company, or organization licensed or registered to issue or who issues any insurance policy or insurance contract in this state as described in Arkansas Code §§ 23-62-102, 23-62-104, 23-62-105, 23-62-106, and 23-62-107 providing medical or hospital benefits for accidental injury or disability;
   6. (9) “Health claimant” means a health insured, a provider holding a valid assignment from the health insured, or a provider contracted with a health carrier, who is claiming a benefit under a health insurance contract;

   7. (10) "Health claim processing” or “to process a health claim” means to:

      1. (A) Pay the claim;
      2. (B) Deny the claim; or
      3. (C) Notify the health claimant in accordance with 23 CAR §§ 15-110(c) and 15-111(b) that the health carrier needs additional information to process the health claim;
   8. (11) “Health claim processing date” or “health claim payment date” is the date the health carrier transmits or mails its claim payment, claim denial, or notice of the need for additional information to the health claimant;

   9. (12)

      1. (A) “Health insurance contract” means a disability insurance policy, a hospital medical service corporation contract, a health maintenance organization contract, or a plan document issued or provided by a health carrier as defined in subdivision (8) of this section.

      2. (B) Health insurance contract shall not include:

         1. (i) A disability income insurance policy;
         2. (ii) A long-term care contract;
         3. (iii) A hospital indemnity contract;
         4. (iv) An accident only contract; or
         5. (v) Any other form of disability insurance policy that provides a benefit as a result of a sickness or accident that does not directly cover expenses related to healthcare treatment the insured receives;
   10. (13) “Health insured” means an individual who is a covered person under a "health insurance contract";
   11. (14) “Health policyholder” means the person who owns the "health insurance contract" and is responsible to pay premiums for the "health insurance contract";
   12. (15) "Insurance department complaint" means a written communication regarding a complaint transmitted by the State Insurance Department;
   13. (16) "Insurer" means any person or risk retention group licensed or registered to issue or who issues any insurance policy or contract in this state;

   14. (17) "Investigation" means all activities of an insurer directly or indirectly related to determination of liabilities or obligations under coverages afforded by a:

       1. (A) Policy;
       2. (B) Contract; or
       3. (C) Healthcare plan;
   15. (18) "Notification of claim" means any notification, whether in writing or by other means acceptable under the terms of an insurance policy, contract, or healthcare plan to an insurer or its agent by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim;

   16. (19) “Provider” means a:

       1. (A) Physician;
       2. (B) Hospital; or
       3. (C) Other appropriately licensed healthcare provider;
   17. (20) "Risk retention group" means a group as defined under Arkansas Code § 23-94-102(10);
   18. (21) "Third-party claimant" means any individual, corporation, association, partnership, or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy or insurance contract; and
   19. (22) "Workers' compensation" includes, but is not limited to, longshore and harbor workers’ compensation.

Codification Notes: Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted as Pub. L. No. 104-191.