P.R. Laws tit. 26, § 3102
For purposes of this chapter, the following terms or phrases shall have the meaning stated below, unless other meaning is clearly inferred from their context:
(1) Health care plan.— Means that which is defined as “health care plan” in § 1902 of this title.
(2) Person.— Means a natural person, association, insurer, group, union, trust, company, partnership, organization, corporation or any other juridical entity.
(3) Provider.— Means all physicians, hospitals, primary services centers, diagnosis and treatment centers, dentists, laboratories, pharmacies, emergency medical services, pre-hospital services, medical equipment providers, or any other persons authorized in Puerto Rico to provide health care services, whether on a group or an individual basis, and which by virtue of a contract with a health services organization and third-party administrators, render health care services to subscribers or beneficiaries of a health care plan.
(4) Health services organization.— Means that which is defined as “health services organization” in § 1902 of this title. For purposes of this chapter, this definition shall include disability insurers authorized to underwrite health insurance, pursuant to §§ 301–335 of this title.
(5) Health care services providing entity.— Means any person who offers or commits to provide health services to one or more health care plans, pursuant to the Insurance Code.
(6) Provider representative.— Means a third party authorized by the provider to negotiate on its behalf with health services organizations, the terms and conditions of the contract by and between the parties and the provider, which shall have:
(a) The authority and the powers conferred thereupon.
(b) A term to discharge such a function.
(c) A valid method to attest to the delegation of such a power or authority.
(d) A person with the authority to confer powers thereupon.
(e) Validity of the contract.
(f) Enforceable civil liability, and the person upon which it is binding.
(7) Third-party administrators.— It is a public or private organization that processes claims from providers without assuming any risk. These are usually contracted by health services organizations or other self-insuring companies, so that these administer services such as: claims processing, collection of premiums, contracting of providers, payments to providers, and administrative activities.
For the purposes of this chapter, the terms shall have the meaning stated above, but in case of controversy concerning the scope thereof, the definitions stated in §§ 103, 105 and 1902 of this title shall be used in a suppletory manner.
History —Ins. Code, added as § 31.020 on Aug. 8, 2008, No. 203, § 1, eff. 90 days after Aug. 8, 2008.