2019 Arkansas Code
Title 23 - Public Utilities and Regulated Industries
Subtitle 3 - Insurance
Chapter 99 - Healthcare Providers
Subchapter 13 - Assignment of Benefits
§ 23-99-1301. Definitions
- As used in this subchapter:
(1) “Contracting entity” means a healthcare insurer or any subcontractor, affiliate, or other entity that contracts directly or indirectly with a healthcare provider for the delivery of healthcare services to enrollees;
(2) “Enrollee” means a person who is entitled to receive healthcare services under the terms of a health benefit plan;
(3)
(A) “Health benefit plan” means a plan, policy, contract, certificate, agreement, or other evidence of coverage for healthcare services offered or issued by a healthcare insurer in this state.
(B) “Health benefit plan” does not include:
(i) A disability income plan;
(ii) A credit insurance plan;
(iii) Insurance coverage issued as a supplement to liability insurance;
(iv) Medical payments under an automobile or homeowners insurance plan;
(v) A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., or the Public Employee Workers' Compensation Act, § 21-5-601 et seq.;
(vi) A plan that provides only indemnity for hospital confinement;
(vii) An accident-only plan;
(viii) A specified disease plan;
(ix) A long-term care insurance plan;
(x) A dental-only plan; or
(xi) A vision-only plan;
(4) “Healthcare contract” means a contract entered into, materially amended, or renewed between a contracting entity and a healthcare provider for the delivery of healthcare services to enrollees;
(5)
(A) “Healthcare insurer” means an entity that is subject to state insurance regulation and provides health insurance in this state.
(B) “Healthcare insurer” includes:
(i) An insurance company;
(ii) A health maintenance organization;
(iii) A hospital and medical service corporation;
(iv) A risk-based provider organization; and
(v) A sponsor of a nonfederal self-funded governmental plan;
(6) “Healthcare provider” means a person or entity that is licensed, certified, or otherwise authorized by the laws of this state to provide healthcare services;
(7) “Healthcare services” means services or goods provided for the purpose of preventing, diagnosing, treating, alleviating, relieving, curing, or healing human illness, disease, condition, disability, or injury;
(8) “Out-of-network provider” means a healthcare provider that provides healthcare services to an enrollee but is not a participating provider;
(9) “Participating provider” means a healthcare provider that has a healthcare contract with a contracting entity to provide healthcare services to enrollees with the expectation of receiving payment either directly from the contracting entity or from a healthcare insurer affiliated with the contracting entity; and
(10) “Payor” means a contracting entity or healthcare insurer responsible for payment for healthcare services provided to an enrollee under the terms of a healthcare contract or a health benefit plan.
