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

1. (1) Abusive practice--a practice that:

   1. (A) does not meet professionally recognized standards for health care or insurance claims adjusting; or
   2. (B) does not meet standards required by statute, rules, or previous notification to system participant; or

   3. (C) is inconsistent with sound fiscal, business, or medical practices and that results in:

      1. (i) unnecessary system costs or in reimbursement for services that are not medically necessary; or
      2. (ii) improper reduction or increase of benefits.
2. (2) Administrative Law Judge--an administrative law judge (ALJ) designated by the State Office of Administrative Hearings (SOAH) to preside over the hearing, or a hearing officer of a state or federal tribunal which would include commission hearing officers and appeals panel judges.
3. (3) Agent--a person or entity that a system participant (insurance carrier, health care provider, employer, employee, or attorney) contracts with or utilizes for the purpose of providing claims service or fulfilling duties under the Statute and Rules. The system participant that the agent works on behalf of is responsible for the acts and omissions of that agent executed in performance of services for the participant.
4. (4) Charged Person (also Alleged Violator)--the person who is charged with an administrative violation or wrongful act. As used in these Rules, charged person includes both person(s) initially charged and those found guilty of an administrative violation(s).
5. (5) Compliance--a person is in compliance if the person timely and accurately fulfills his duties under the Statute and Rules in the form and manner required (does not commit a violation by an act of omission or commission) and if the person does not commit an act which is prohibited.
6. (6) Continued Noncompliance (also Active Noncompliance)--a person is in "continued noncompliance" if the person has committed a violation of the Statute or Rules and has yet to take action to come into full compliance. For example, a person who fails to file a required report (or who files an incomplete report) would be in "continued noncompliance". The person could come into compliance by filing a properly completed report (although, doing so would not eliminate the existence of a violation for failing to timely file a complete report in the first place).
7. (7) Controlled substances--"controlled substance" as defined by the Texas Controlled Substances Act (Texas Civil Statutes, Article 4476-15) or its successor and the Federal Controlled Substances Act (21 USCA §8.01 et seq.) or its successor.

8. (8) Conviction or convicted--

   1. (A) A person is considered to have been convicted when:

      1. (i) a judgment of conviction has been entered against the person in a federal, state, or local court;
      2. (ii) the person has been found guilty in a federal, state, or local court;
      3. (iii) the person has entered a plea of guilty or nolo contendere (no contest) that has been accepted by a federal, state, or local court;
      4. (iv) the person has entered a first offender or other program and judgment of conviction has been withheld; or
      5. (v) the person has received probation or community supervision, including deferred adjudication.

   2. (B) A conviction is still a conviction until and unless overturned on appeal even if:

      1. (i) it is stayed, deferred, or probated;
      2. (ii) an appeal is pending;
      3. (iii) the judgment of conviction or other record related to the conduct is expunged; or
      4. (iv) the person has been discharged from probation or community supervision, including deferred adjudication.
9. (9) Emergency--as defined in §133.1 of this Title (relating to Definitions for chapter 133).
10. (10) Frivolous--that which does not have a basis in fact or is not warranted by existing law or a good faith argument for the extension, modification, or reversal of existing law.
11. (11) Immediate post-injury medical care--that health care provided on the date that the employee first seeks medical attention for the workers' compensation injury.
12. (12) Intentionally--a person acts intentionally with respect to the nature of his conduct or to a result of his conduct when it is his conscious objective or desire to engage in the conduct or cause the result.
13. (13) Knowingly--a person acts knowingly with respect to the nature of his conduct or to circumstances surrounding his conduct when he is aware of the nature of his conduct or that the circumstances exist. A person acts knowingly with respect to a result of his conduct when he is aware that his conduct is reasonably certain to cause the result.
14. (14) Noncompliance or Noncompliant Act--a violation of the Statute or Rules.
15. (15) Pattern of Practice--the acts or omissions of a participant in the workers' compensation system which are repeated. This term is synonymous with similar terms such as "business practice," "pattern of conduct," "matter of practice," etc.
16. (16) Rules--the commission's rules adopted under this Statute.
17. (17) Remuneration--any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind, including, but not limited to, forgiveness of debt.

18. (18) Significant Violation--a violation which:

    1. (A) based upon the facts surrounding it, raises reasonable concern about a system participant's ability to conform its future conduct to applicable laws or rules;
    2. (B) resulted or could have resulted in significant physical or emotional harm to an injured employee;
    3. (C) resulted or could have resulted in significant economic harm to a system participant; or
    4. (D) was either willfully committed or which is part of an uncorrected pattern of practice.
19. (19) SOAH--the State Office of Administrative Hearings.
20. (20) System Participant--a person or entity required to comply with the Statute and Rules. This will generally be an insurance carrier (carrier), employer, health care provider (provider or HCP), attorney, injured employee (employee) or other claimant.
21. (21) Uncorrected Pattern of Practice--a pattern of practice which continues even after the commission provides written notice to the person committing the violation(s) of the noncompliance.
22. (22) Violation--a failure to comply with a duty established under the Statute or Rules or commission of an act prohibited by the Statute or Rules.
23. (23) Violator--a person found to have committed an administrative violation or another offense.
24. (24) Willfully--intentionally or knowingly. Also, continuing conduct after being notified by the commission or other regulatory authority. NOTE - "wilful" and " wilfully" as used in the Statute are the same as "willful" and "willfully," respectively.

Source Note:The provisions of this §180.1 adopted to be effective July 29, 1991, 16 TexReg 3940; amended to be effective March 14, 2002, 27 TexReg 1817.