Tex.
Ins. Code Section 38.402
Definitions
(1)
“Allowed amount” means the amount of a billed charge that a health benefit plan issuer determines to be covered for services provided by a non-network provider. The allowed amount includes both the insurer’s payment and any applicable deductible, copayment, or coinsurance amounts for which the insured is responsible.(2)
“Center” means the Center for Healthcare Data at The University of Texas Health Science Center at Houston.(3)
“Contracted rate” means the fee or reimbursement amount for a network provider’s services, treatments, or supplies as established by agreement between the provider and health benefit plan issuer.(4)
“Data” means the specific claims and encounters, enrollment, and benefit information submitted to the center under this subchapter.(5)
“Database” means the Texas All Payor Claims Database established under this subchapter.(6)
“Geozip” means an area that includes all zip codes with identical first three digits.(7)
“Payor” means any of the following entities that pay, reimburse, or otherwise contract with a health care provider for the provision of health care services, supplies, or devices to a patient:(A)
an insurance company providing health or dental insurance;(B)
the sponsor or administrator of a health or dental plan;(C)
a health maintenance organization operating under Chapter 843 (Health Maintenance Organizations);(D)
the state Medicaid program, including the Medicaid managed care program operating under Chapter 533, Government Code;(E)
a health benefit plan offered or administered by or on behalf of this state or a political subdivision of this state or an agency or instrumentality of the state or a political subdivision of this state, including:(i)
a basic coverage plan under Chapter 1551 (Texas Employees Group Benefits Act);(ii)
a basic plan under Chapter 1575 (Texas Public School Employees Group Benefits Program);(iii)
a primary care coverage plan under Chapter 1579 (Texas School Employees Uniform Group Health Coverage); and(iv)
a plan providing basic coverage under Chapter 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&m University System); or(F)
any other entity providing a health insurance or health benefit plan subject to regulation by the department.(7)
“Payor” means any of the following entities that pay, reimburse, or otherwise contract with a health care provider for the provision of health care services, supplies, or devices to a patient:(A)
an insurance company providing health or dental insurance;(B)
the sponsor or administrator of a health or dental plan;(C)
a health maintenance organization operating under Chapter 843 (Health Maintenance Organizations);(D)
the state Medicaid program, including the Medicaid managed care program operating under Chapters 540 (Medicaid Managed Care Program) and 540A (Medicaid Managed Transportation Services), Government Code;(E)
a health benefit plan offered or administered by or on behalf of this state or a political subdivision of this state or an agency or instrumentality of the state or a political subdivision of this state, including:(i)
a basic coverage plan under Chapter 1551 (Texas Employees Group Benefits Act);(ii)
a basic plan under Chapter 1575 (Texas Public School Employees Group Benefits Program);(iii)
a primary care coverage plan under Chapter 1579 (Texas School Employees Uniform Group Health Coverage); and(iv)
a plan providing basic coverage under Chapter 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&m University System); or(F)
any other entity providing a health insurance or health benefit plan subject to regulation by the department.(8)
“Protected health information” has the meaning assigned by 45 C.F.R. Section 160.103.(9)
“Qualified research entity” means:(A)
an organization engaging in public interest research for the purpose of analyzing the delivery of health care in this state that is exempt from federal income tax under Section 501(a), Internal Revenue Code of 1986, by being listed as an exempt organization in Section 501(c)(3) of that code;(B)
an institution of higher education engaged in public interest research related to the delivery of health care in this state; or(C)
a health care provider in this state engaging in efforts to improve the quality and cost of health care.(10)
“Stakeholder advisory group” means the stakeholder advisory group established under Section 38.403 (Stakeholder Advisory Group).
Source:
Section 38.402 — Definitions, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.38.htm#38.402 (accessed May 18, 2024).
