Section 19.1803 - DefinitionsThe following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:
(1) CDT--Current Dental Terminology code set maintained by the American Dental Association.(2) CPT--Current Procedural Terminology code set maintained by the American Medical Association.(3) Department or TDI--Texas Department of Insurance.(4) Form--In Division 2 of this subchapter, the Texas Standard Prior Authorization Request Form for Health Care Services. In Division 3 of this subchapter, the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits.(5) HCPCS--Healthcare Common Procedure Coding System.(6) Health benefit plan-- (A) a plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document offered by a health benefit plan issuer.(B) Health benefit plan also includes:(i) group health coverage made available by a school district in accord with Education Code § 22.004;(ii) coverage under the child health program in Health and Safety Code Chapter 62, or the health benefits plan for children in Health and Safety Code Chapter 63;(iii) a Medicaid managed care program operated under Government Code Chapter 533, or a Medicaid program operated under Human Resources Code Chapter 32;(iv) a basic coverage plan under Insurance Code Chapter 1551;(v) a basic plan under Insurance Code Chapter 1575;(vi) a primary care coverage plan under Insurance Code Chapter 1579; and(vii) basic coverage under Insurance Code Chapter 1601.(7) Health benefit plan issuer--An entity authorized under the Insurance Code or another insurance law of this state that delivers or issues for delivery a health benefit plan or other coverage described in Insurance Code § 1217.002 or Insurance Code § 1369.252.(8) Health care service--A service to diagnose, prevent, alleviate, cure, or heal a human illness or injury that is provided by a physician or other health care provider. The term includes medical or health care treatments, consultations, procedures, drugs, supplies, imaging and diagnostic services, inpatient and outpatient care, medical devices other than those included in the definition of prescription drugs in Occupations Code § 551.003, and durable medical equipment. The term does not include prescription drugs or devices as defined by Occupations Code § 551.003.(9) ICD--International Classification of Diseases.(10) Issuer--A health benefit plan issuer and the agent of a health benefit plan issuer that manages or administers the issuer's health care services or prescription drug benefits.(11) NDC--National Drug Code.(12) NPI number--A provider's or facility's National Provider Identifier.(13) Prescription drug--Has the meaning assigned by Occupations Code § 551.003.28 Tex. Admin. Code § 19.1803
Adopted by Texas Register, Volume 39, Number 50, December 12, 2014, TexReg 9702, eff. 9/1/2015; Amended by Texas Register, Volume 40, Number 16, April 17, 2015, TexReg 2195, eff. 9/1/2015; Amended by Texas Register, Volume 47, Number 31, August 5, 2022, TexReg 4686, eff. 8/11/2022