§ 26.1-47-01 — Definitions

North Dakota § 26.1-47-01

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-47: Preferred Provider Organizations

Text

As used in this chapter, unless the context indicates otherwise:
1. "Air ambulance" means a specially equipped aircraft licensed by the department of
health and human services for transporting patients.
2. "Air ambulance provider" means a publicly or privately owned organization that is
licensed or applies for licensure by the department of health and human services to
provide transportation and care of patients by air ambulance.
3. "Authorized representative" means:
a. A person to which a covered person has given express written consent to
represent the covered person;
b. A person authorized by law to provide substituted consent for a covered person;
or
c. If a covered person is unable to provide consent, the covered person's treating
health care professional or a family member of the covered person.
4. "Balance billing" means the practice of an air ambulance provider billing for the
difference between the air ambulance provider's charge and the health care insurer's
allowed amount.
5. "Commissioner" means the insurance commissioner of the state of North Dakota.
6. "Covered person" means an individual on whose behalf the health care insurer is
obligated to pay for or provide health care services.
7. "Facility" means an institution or other immobile health care setting providing physical,
mental, or behavioral health care services.
8. "Health benefit plan" means the health insurance policy or subscriber agreement
between the covered person or the policyholder and the health care insurer which
defines the services covered.
9. "Health care insurer" includes an insurance company as defined in section 26.1-02-01,
a health service corporation as defined in section 26.1-17-01, a health maintenance
organization as defined in section 26.1-18.1-01, and a fraternal benefit society as
defined in section 26.1-15.1-02.
10. "Health care provider" means licensed providers of health care services in this state.
11. "Health care services" means services rendered or products sold by a health care
provider within the scope of the provider's license. The term includes hospital, medical,
surgical, dental, vision, chiropractic, and pharmaceutical services or products.
12. "Network" means a group of preferred providers providing services under a network
plan.
13. "Network plan" means a health benefit plan that requires a covered person to use, or
creates incentives, including financial incentives, for a covered person to use health
care providers managed by, owned by, under contract with, or employed by the health
care insurer.
14. "Out-of-network" means a provider that is not providing the service under a network
plan.
15. "Preferred provider" means a duly licensed health care provider or group of providers
who have contracted with the health care insurer, under this chapter, to provide health
care services to covered persons under a health benefit plan.
16. "Preferred provider arrangement" means a contract between the health care insurer
and one or more health care providers which complies with all the requirements of this
chapter.
17. "Prior authorization" means confirmation by the covered person's health care insurer
that the air ambulance services sought to be provided by the air ambulance provider
meet the criteria for coverage under the covered person's health benefit plan as
defined by the provisions of the covered person's health benefit plan.