“Appropriate and medically necessary” means the standard for health care services as determined by physicians and health care providers in accordance with the prevailing practices and standards of the medical profession and community.
“Enrollee” means an individual who is enrolled in a health care plan, including covered dependents.
“Health care plan” means any plan whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services.
“Health care treatment decision” means a determination made when medical services are actually provided by the health care plan and a decision which affects the quality of the diagnosis, care, or treatment provided to the plan’s insureds or enrollees.
“Health insurance carrier” means an authorized insurance company that issues policies of accident and health insurance under Chapter 1201 (Accident and Health Insurance), Insurance Code.
“Managed care entity” means any entity which delivers, administers, or assumes risk for health care services with systems or techniques to control or influence the quality, accessibility, utilization, or costs and prices of such services to a defined enrollee population, but does not include an employer purchasing coverage or acting on behalf of its employees or the employees of one or more subsidiaries or affiliated corporations of the employer or a pharmacy licensed by the State Board of Pharmacy.
an individual licensed to practice medicine in this state;
a professional association organized under the Texas Professional Association Act (Article 1528f, Vernon’s Texas Civil Statutes) or a nonprofit health corporation certified under Section 5.01, Medical Practice Act (Article 4495b, Vernon’s Texas Civil Statutes); or
another person wholly owned by physicians.
“Ordinary care” means, in the case of a health insurance carrier, health maintenance organization, or managed care entity, that degree of care that a health insurance carrier, health maintenance organization, or managed care entity of ordinary prudence would use under the same or similar circumstances. In the case of a person who is an employee, agent, ostensible agent, or representative of a health insurance carrier, health maintenance organization, or managed care entity, “ordinary care” means that degree of care that a person of ordinary prudence in the same profession, specialty, or area of practice as such person would use in the same or similar circumstances.Added by Acts 1997, 75th Leg., ch. 163, Sec. 1, eff. Sept. 1, 1997. Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.508, eff. Sept. 1, 2003.Amended by:Acts 2005, 79th Leg., Ch. 134 (H.B. 737), Sec. 1, eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.107, eff. September 1, 2005.