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304.17A-500 Definitions for KRS 304.17A-500 to 304.17A-590.
As used in KRS 304.17A-500 to 304.17A-590, unless the context requires otherwise:
(1) "Areas other than urban areas" means a classification code that does not meet
the definition of urban area;
(2) "Contract holder" means an employer or organization that purchases a health
benefit plan;
(3) "Covered person" means a person on whose behalf an insurer offering the plan
is obligated to pay benefits or provide services under the health insurance
policy;
(4) "Emergency medical condition" means:
(a) A medical condition manifesting itself by acute symptoms of sufficient
severity, including severe pain, that a prudent layperson would
reasonably have cause to believe constitutes a condition that the absence
of immediate medical attention could reasonably be expected to result in:
1.
Placing the health of the individual or, with respect to a pregnant
woman, the health of the woman or her unborn child, in serious
jeopardy;
2.
Serious impairment to bodily functions; or
3.
Serious dysfunction of any bodily organ or part; or
(b) With respect to a pregnant woman who is having contractions:
1.
A situation in which there is inadequate time to effect a safe transfer
to another hospital before delivery; or
2.
A situation in which transfer may pose a threat to the health or
safety of the woman or the unborn child;
(5) "Enrollee" means a person who is enrolled in a plan offered by a health
maintenance organization as defined in KRS 304.38-030(5);
(6) "Grievance" means a written complaint submitted by or on behalf of an
enrollee;
(7) "Health insurance policy" means "health benefit plan" as defined in KRS
304.17A-005;
(8) "Insurer" has the meaning provided in KRS 304.17A-005;
(9) "Managed care plan" means a health insurance policy that integrates the
financing and delivery of appropriate health care services to enrollees by
arrangements with participating providers who are selected to participate on
the basis of explicit standards to furnish a comprehensive set of health care
services and financial incentives for enrollees to use the participating providers
and procedures provided for in the plan;
(10) "Participating health care provider" means a health care provider that has
entered into an agreement with an insurer to provide health care services;
(11) "Quality assurance or improvement" means the ongoing evaluation by a
managed care plan of the quality of health care services provided to its
enrollees;
(12) "Record" means any written, printed, or electronically recorded material
maintained by a provider in the course of providing health services to a patient
concerning the patient and the services provided. "Record" also includes the
substance of any communication made by a patient to a provider in confidence
during or in connection with the provision of health services to a patient or
information otherwise acquired by the provider about a patient in confidence
and in connection with the provision of health services to a patient;
(13) "Risk sharing arrangement" means any agreement that allows an insurer to
share the financial risk of providing health care services to enrollees or
insureds with another entity or provider where there is a chance of financial
loss to the entity or provider as a result of the delivery of a service. A risk
sharing arrangement shall not include a reinsurance contract with an
accredited or admitted reinsurer;
(14) "Urban area" means a classification code whereby the zip code population
density is greater than three thousand (3,000) persons per square mile; and
(15) "Utilization management" means a system for reviewing the appropriate and
efficient allocation of health care services under a health benefits plan
according to specified guidelines, in order to recommend or determine whether,
or to what extent, a health care service given or proposed to be given to a
covered person should or will be reimbursed, covered, paid for, or otherwise
provided under the plan. The system may include preadmission certification,
the application of practice guidelines, continued stay review, discharge
planning, preauthorization of ambulatory care procedures, and retrospective
review.
Effective:July 13, 2004
History: Amended 2004 Ky. Acts ch. 59, sec. 6, effective July 13, 2004. -Amended 2000 Ky. Acts ch. 500, sec. 5, effective July 14, 2000. -- Created 1998
Ky. Acts ch. 496, sec. 25, effective April 10, 1998.
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