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

1. (1) Act--Insurance Code, Article 21.58C, entitled Standards for Independent Review Organizations.
2. (2) Active practice--20 hours per week in the examination, diagnosis, and/or treatment of patients.
3. (3) Administrator--A person holding a certificate of authority under the Insurance Code, Article 21.07-6.
4. (4) Adverse determination--A determination made on behalf of any payor that the health care services furnished or proposed to be furnished to a patient are not medically necessary or not appropriate.
5. (5) Affiliate--A person who directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with the person specified.
6. (6) Commissioner--The Commissioner of Insurance.
7. (7) Department--Texas Department of Insurance.
8. (8) Dental plan--An insurance policy or health benefit plan, including a policy written by a company subject to the Insurance Code, Chapter 20, that provides coverage for expenses for dental services.
9. (9) Dentist--A licensed doctor of dentistry holding either a D.D.S. or a D.M.D. degree.

10. (10) Emergency care--Health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

    1. (A) placing the patient's health in serious jeopardy;
    2. (B) serious impairment to bodily functions;
    3. (C) serious dysfunction of any bodily organ or part;
    4. (D) serious disfigurement; or
    5. (E) in the case of a pregnant woman, serious jeopardy to the health of the fetus.
11. (11) Health benefit plan--A plan of benefits that defines the coverage provisions for health care offered or provided by any organization, public or private, other than health insurance.
12. (12) Health care provider--Any person, corporation, facility or institution, licensed by a state to provide or otherwise lawfully providing health care services, that is eligible for independent reimbursement for those services.
13. (13) Health insurance policy--An insurance policy, including a policy subject to the Insurance Code, Chapter 20, that provides coverage for medical or surgical expenses incurred as a result of accident or sickness.
14. (14) Independent review--A system for final administrative review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual who resides within the state by a designated independent review organization.
15. (15) Independent review organization--An entity that is certified by the commissioner to conduct independent review under the authority of the Act. Such entity must have the capacity for independent review of all specialty classifications and subspecialties thereof contained in the two tiered structure of specialty classifications set forth in §12.402 of this title (relating to Classifications of Specialty).
16. (16) Independent review plan--The screening criteria and review procedures of an independent review organization.
17. (17) Life-threatening condition--A disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

18. (18) Medical and scientific evidence--Evidence derived from the following sources:

    1. (A) Peer reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
    2. (B) Peer reviewed literature, biomedical compendia and other medical literature that meet the criteria of the National Institute of Health's National Library of Medicine for indexing in Index Medicus, Excerpt--Medicus (EMBASE), Medline, and MEDLARS database Health Services Technology Assessment Research (HSTAR).
    3. (C) Medical journals recognized by the Secretary of Health and Human Services, under Section 1961(t)(2) of the Social Security Act.
    4. (D) The following standard reference compendia: the American Hospital Formulary Service Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia--Drug Information.
    5. (E) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the Federal Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Health Care Financing Administration, Congressional Office of Technology Assessment, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services.
    6. (F) Peer reviewed abstracts accepted for presentation at major medical association meetings.
19. (19) Nurse--A professional or registered nurse, licensed vocational nurse, or licensed practical nurse.
20. (20) Open records law--Chapter 552, Government Code.
21. (21) Patient--A person covered by a health insurance policy or health benefit plan on whose behalf independent review is sought. This term includes a person who is covered as an eligible dependent of another person.
22. (22) Payor--An insurer writing health insurance policies; any health maintenance organization, self-insurance plan, or any other person or entity which provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to persons treated by a health care provider in this state pursuant to any policy, plan, or contract.
23. (23) Person--An individual, corporation, partnership, association, joint stock company, trust, unincorporated organization, any similar entity, or any combination of the foregoing acting in concert.
24. (24) Physician--A licensed doctor of medicine or a doctor of osteopathy.
25. (25) Provider of record--The physician or other health care provider that has primary responsibility for the care, treatment, and services rendered or requested on behalf of the patient, or the physician or health care provider that has rendered or has been requested to provide the care, treatment, and/or services to the patient. This definition includes any health care facility where treatment is rendered on an inpatient or outpatient basis.
26. (26) Screening criteria--The written policies, medical protocols, previous decisions and/or guidelines used by the independent review organization to make preliminary decisions about the medical necessity and appropriateness of a treatment, procedure, or service.
27. (27) Utilization review agent--A person holding a certificate of registration under the Insurance Code, Article 21.58A.
28. (28) Working day--A weekday, excluding New Years Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, and Christmas Day.

Source Note:The provisions of this §12.5 adopted to be effective November 26, 1997, 22 TexReg 11363.