The following words and terms when used in this subchapter shall have the following meanings:

1. (1) Audit -- An instance in which an HMO acknowledges coverage of an enrollee under the health care plan or a preferred provider carrier acknowledges coverage of an insured under the health insurance policy but exceeds the statutory claims payment period while processing a clean claim or a portion of a clean claim.
2. (2) Billed charges -- The charges made by a physician or provider who renders or furnishes services, treatments, or supplies provided the charge is not in excess of the general level of charges made by other physicians or providers who render or furnish the same or similar services, treatments, or supplies to persons in the same geographical area and whose illness or injury is comparable in nature or severity. In the event of a case rate agreed to between the physician or provider and the HMO or preferred provider carrier, billed charges shall be considered the higher of the case rate or billed charges.
3. (3) Case rate -- A method of compensation in which a physician or provider receives one negotiated payment for all care rendered for a particular procedure or a specific diagnosis.

4. (4) Clean claim -- A claim submitted by a physician or provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy with documentation reasonably necessary for the HMO or preferred provider carrier to process the claim, which contains:

   1. (A) the required data elements set forth in §21.2803(b) of this title (relating to Elements of a Clean Claim);
   2. (B) the attachments of which the physician or provider has been properly notified as necessary for processing pursuant to §§21.2803(c) of this title (relating to Elements of a Clean Claim) and 21.2804 of this title (relating to Disclosure of Necessary Attachments);
   3. (C) any additional elements of which the physician or provider has been properly notified pursuant to §§21.2803(d) of this title (relating to Elements of a Clean Claim) and 21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements);
   4. (D) the amount paid by the primary plan or other valid coverage pursuant to §21.2803(e) of this title (relating to Elements of a Clean Claim), if applicable; and
   5. (E) any revised data elements, attachments, and additional clean claim elements of which the physician or provider has been properly notified pursuant to §21.2806 of this title (relating to Disclosure of Revision of Data Elements, Attachments, or Additional Clean Claim Elements).
5. (5) Condition code -- The code utilized by HCFA to identify conditions that may affect processing of the claim.
6. (6) Contracted rate -- Fee or reimbursement amount for a physician's or provider's services, treatments, or supplies as established by agreement between the physician or provider and the HMO or preferred provider carrier.
7. (7) Deficient claim -- A submitted claim that does not contain the required clean claim elements pursuant to §21.2803(a) of this title.
8. (8) Delegated claims processor -- A licensed third party administrator to which an HMO or preferred provider carrier has delegated claims processing functions.
9. (9) Diagnosis code -- The ICD-9-CM code number. Narrative diagnoses for non-physician specialties shall be submitted on an attachment.
10. (10) HCFA -- The Health Care Financing Administration of the U.S. Department of Health and Human Services.
11. (11) HMO -- A health maintenance organization as defined by Insurance Code Article 20A.02(n).
12. (12) HMO delivery network -- As defined by Insurance Code Article 20A.02(w).
13. (13) Institutional provider -- An institution providing health care services, including but not limited to hospitals, other licensed inpatient centers, ambulatory surgical centers, skilled nursing centers and residential treatment centers.
14. (14) Occurrence span code -- The code utilized by HCFA to define a specific event relating to the billing period.
15. (15) Patient control number -- A unique alphanumeric identifier assigned by the institutional provider to facilitate retrieval of individual financial records and posting of payment.
16. (16) Patient-status-at-discharge code -- The code utilized by HCFA to indicate the patient's status at time of discharge or billing.

17. (17) Physician or provider --

    1. (A) with regard to a preferred provider carrier, a preferred provider as defined by Insurance Code Article 3.70-3C, §1(10) (Preferred Provider Benefit Plans) or Article 3.70-3C, §1(1) (Use of Advanced Practice Nurses and Physician Assistants by Preferred Provider Plans).

    2. (B) with regard to an HMO,

       1. (i) a physician, as defined by Insurance Code Article 20A.02(r), who is a member of that HMO's delivery network; or
       2. (ii) a provider, as defined by Insurance Code Article 20A.02(t), who is a member of that HMO's delivery network.
18. (18) Place of service code -- The codes utilized by HCFA that identify the place at which the service was rendered.
19. (19) Preferred provider carrier -- An insurer that issues a preferred provider benefit plan as provided by Insurance Code Article 3.70-3C, Section 2 (Preferred Provider Benefit Plans).
20. (20) Primary plan -- As defined in §3.3506 of this title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan," and "This Plan" in Policies, Certificates and Contracts).
21. (21) Procedure code -- The HCFA Common Procedure Coding System (HCPCS) number, including CPT codes. In the absence of an existing HCPCS code or other commonly used code, this item may also apply to local codes developed specifically by Medicaid, Medicare, an HMO, or preferred provider carrier to describe a specific service or procedure.
22. (22) Revenue code -- The code assigned by HCFA to each cost center for which a separate charge is billed.
23. (23) Secondary plan -- As defined in §3.3506 of this title.
24. (24) Source of admission code -- The code utilized by HCFA to indicate the source of an inpatient admission.

25. (25) Statutory claims payment period --

    1. (A) the 45-calendar-day, or other time period not to exceed 45 calendar days set forth by written agreement between the physician or provider and the HMO or preferred provider carrier, in which claim payment or denial, in whole or in part, shall be made by an HMO or preferred provider carrier after receipt of a clean claim pursuant to Insurance Code Article 3.70-3C, §3(m) (Preferred Provider Benefit Plans), and Article 20A.09(j);
    2. (B) the 45-calendar-day period in which claim payment or denial, in whole or in part, shall be made by an HMO or preferred provider carrier after receipt of a clean claim pursuant to Insurance Code Article 3.70-3C, §3A (Preferred Provider Benefit Plans) and Article 20A.18B; or
    3. (C) the 21-calendar-day period in which claim payment or denial, in whole or in part, shall be made by an HMO or preferred provider carrier after receipt of an electronically submitted clean claim for a prescription benefit that is electronically adjudicated and electronically paid pursuant to Insurance Code Article 3.70-3C, §3A(d) (Preferred Provider Benefit Plans) and Article 20A.18B(d), and §21.2814 of this title (relating to Electronic Adjudication of Prescription Benefits).
26. (26) Subscriber -- If individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the HMO or preferred provider carrier; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in a group health benefit plan issued by the HMO or the preferred provider carrier.
27. (27) Type of bill code -- The three-digit alphanumeric code utilized by HCFA to identify the type of facility, the type of care, and the sequence of the bill in a particular episode of care.

Source Note:The provisions of this §21.2802 adopted to be effective May 23, 2000, 25 TexReg 4543.