§ 27-20.10-1 - Definitions. - Rhode Island Statutes

SECTION 27-20.10-1

   § 27-20.10-1  Definitions. – For purposes of this chapter, the following definitions shall apply:

   (1) "Contracting entity" means any person or entity thatenters into direct contracts with providers for the delivery of health careservices in the ordinary course of business.

   (2) "Control" and "under common control with" shall meanpossession, directly or indirectly, of the power to direct or cause thedirection of the management and policies of an entity through the ownership offifty percent (50%) or more of the voting securities of the entity.

   (3) "Covered individual" means an individual who is coveredunder a health insurance plan.

   (4) "Department" means the department of business regulation.

   (5) "Direct notification" is a written or electroniccommunication from a contracting entity to a provider documenting a third-partyaccess to a provider network.

   (6) "Health care services" means services for the diagnosis,prevention, treatment or cure of a health condition, illness, injury or disease.

   (7) "Health insurance plan" means any hospital and medicalexpense incurred policy, nonprofit health care service plan contract, healthmaintenance organization subscriber contract, or any other health care plan orarrangement that pays for or furnishes medical or health care services, whetherby insurance or otherwise.

   (ii) "Health insurance plan" shall not include one or more,or any combination of, the following: coverage only for accident, or disabilityincome insurance; coverage issued as a supplement to liability insurance;liability insurance, including general liability insurance and automobileliability insurance; workers' compensation or similar insurance; automobilemedical payment insurance; credit-only insurance; coverage for on-site medicalclinics; coverage similar to the foregoing as specified in federal regulationissued pursuant to P.L. No. 104-191, under which benefits for medical care aresecondary or incidental to other insurance benefits; dental or vision benefits;benefits for long-term care, nursing home care, home health care, orcommunity-based care; specified disease or illness coverage, hospital indemnityor other fixed indemnity insurance, or such other similar, limited benefits asare specified in regulations; Medicare supplemental health insurance as definedunder § 1882(g)(1) of the Social Security Act; coverage supplemental tothe coverage provided under chapter 55 of title 10, United States Code; orother similar limited benefit supplemental coverages.

   (8) "Provider" means a physician, a physician organization,or a physician hospital organization that is acting exclusively as anadministrator on behalf of a provider to facilitate the provider'sparticipation in health care contracts.

   (ii) "Provider" does not include a physician organization orphysician hospital organization that leases or rents the physicianorganization's or physician hospital organization's network to a third-party.

   (9) "Provider network contract" means a contract between acontracting entity and a provider specifying the rights and responsibilities ofthe contracting entity and provider for the delivery of and payment for healthcare services to covered individuals.

   (10) "Third-party" means an organization that enters into acontract with a contracting entity or with another third-party to gain accessto a provider network contract.