354.600. Definitions.

MISSOURI STATUTES AND CODES

Definitions.

354.600. For purposes of sections 354.600 to 354.636 the followingterms shall mean:

(1) "Facility", an institution providing health care services or ahealth care setting, including but not limited to hospitals and otherlicensed inpatient centers, ambulatory surgical or treatment centers,skilled nursing facilities, residential treatment centers, diagnostic,laboratory and imaging centers, and rehabilitation and other therapeutichealth settings;

(2) "Health benefit plan", a policy, contract, certificate oragreement entered into, offered or issued by a health carrier to provide,deliver, arrange for, pay for or reimburse any of the costs of health careservices;

(3) "Health care professional", a physician or other health carepractitioner licensed, accredited or certified by the state of Missouri toperform specified health services;

(4) "Health care provider" or "provider", a health care professionalor a facility;

(5) "Health carrier", a health maintenance organization establishedpursuant to sections 354.400 to 354.636;

(6) "Health indemnity plan", a health benefit plan that is not amanaged care plan;

(7) "Intermediary", a person authorized to negotiate and executeprovider contracts with health carriers on behalf of health care providersor on behalf of a network;

(8) "Managed care plan", a health benefit plan that either requiresan enrollee to use, or creates incentives, including financial incentives,for an enrollee to use health care providers managed, owned, under contractwith or employed by the health carrier;

(9) "Network", the group of participating providers providingservices to a managed care plan;

(10) "Participating provider", a provider who, under a contract withthe health carrier or with its contractor or subcontractor, has agreed toprovide health care services to enrollees with an expectation of receivingpayment, other than coinsurance, co-payments or deductibles, directly orindirectly from the health carrier;

(11) "Primary care professional" or "primary care provider", aparticipating health care professional designated by the health carrier tosupervise, coordinate or provide initial care or continuing care to anenrollee, and who may be required by the health carrier to initiate areferral for specialty care and maintain supervision of health careservices rendered to the enrollee.