33-20A-3. Definitions.

As used in this article, the term:

“Emergency services” or “emergency care” means those physical or mental health care services that are provided for a condition of recent onset and sufficient severity, including, but not limited to, severe pain, regardless of the initial, interim, final, or other diagnoses that are given, 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 obtain immediate medical care could result in:#

1. (A)

   Placing the patient’s health in serious jeopardy;#

2. (B)

   Serious impairment to bodily functions; or#

3. (C)

   Serious dysfunction of any bodily organ or part.#

“Enrollee” means an individual who has elected to contract for or participate in a managed care plan for that individual or for that individual and that individual’s eligible dependents.#

“Facility” means a hospital, ambulatory surgical treatment center, birthing center, diagnostic and treatment center, hospice, or similar institution for examination, diagnosis, treatment, surgery, or maternity care but does not include physicians’ or dentists’ private offices and treatment rooms in which such physicians or dentists primarily see, consult with, and treat patients.#

“Health benefit plan” has the same meaning as provided in Code Section 33-24-59.5.#

“Health care provider” or “provider” means any physician, dentist, podiatrist, pharmacist, optometrist, psychologist, clinical social worker, advanced practice nurse, registered optician, licensed professional counselor, physical therapist, marriage and family therapist, chiropractor, athletic trainer qualified pursuant to Code Section 43-5-8, occupational therapist, speech language pathologist, audiologist, dietitian, or physician assistant.#

“Home health care provider” means any provider or agency that provides health care services in a patient’s home including the supply of durable medical equipment for use in a patient’s home.#

“Limited utilization incentive plan” means any compensation arrangement between the plan and a health care provider or provider group that has the effect of reducing or limiting services to patients.#

“Managed care contractor” means a person who:#

1. (A)

   Establishes, operates, or maintains a network of participating providers;#

2. (B)

   Conducts or arranges for utilization review activities; and#

3. (C)

   Contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan.#

“Managed care entity” includes an insurance company, hospital or medical service plan, hospital, health care provider network, physician hospital organization, health care provider, health maintenance organization, health care corporation, employer or employee organization, or managed care contractor that offers a managed care plan.#

“Managed care plan” means a major medical, hospitalization, or dental plan that provides for the financing and delivery of health care services to persons enrolled in such plan through:#

1. (A)

   Arrangements with selected providers to furnish health care services;#

2. (B)

   Explicit standards for the selection of participating providers; and#

3. (C)

   Cost savings for persons enrolled in the plan to use the participating providers and procedures provided for by the plan; provided, however, that the term “managed care plan” does not apply to Chapter 9 of Title 34, relating to workers’ compensation.#

“Nonurgent procedure” means any nonemergency or elective care that can be scheduled at least 24 hours prior to the service without posing a significant threat to the patient’s health or well-being.#

“Out of network” or “point of service” refers to health care items or services provided to an enrollee by providers who do not belong to the provider network in the managed care plan.#

“Patient” means a person who seeks or receives health care services under a managed care plan.#

“Precertification” or “preauthorization” means any written or oral determination made at any time by an insurer or any agent thereof that an enrollee’s receipt of health care services is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such services have been satisfied. “Agent” as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.#

“Qualified managed care plan” means a managed care plan that the Commissioner certifies as meeting the requirements of this article.#

“Verification of benefits” means any written or oral determination by an insurer or agent thereof of whether given health care services are a covered benefit under the enrollee’s health benefit plan without a determination of precertification or preauthorization as to such services. “Agent” as used in this paragraph shall not include an agent or agency as defined in Code Section 33-23-1.#