§ 3802 — Definitions

Pennsylvania § 3802

• Jurisdiction: Pennsylvania
• Title 40: INSURANCE
• Part: PART II
• Ch. 38: RETROACTIVE DENIAL OF REIMBURSEMENTS

Text

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Abuse."Incidents or practices of providers, physicians or suppliers of services and equipment which are inconsistent with accepted sound medical, business or fiscal practices.

"Fraud."Any activity defined as an offense under 18 Pa.C.S. § 4117 (relating to insurance fraud).

"Health care provider."A person, corporation, facility, institution or other entity licensed, certified or approved by the Commonwealth to provide health care or professional medical services. The term includes, but is not limited to, a physician, chiropractor, optometrist, professional nurse, certified nurse-midwife, podiatrist, hospital, nursing home, ambulatory surgical center or birth center.

"Insurer."A health insurance entity licensed in this Commonwealth to issue any individual or group health, sickness or accident policy or subscriber contract or certificate that provides medical or health care coverage by a health care facility or licensed health care provider that is offered or governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV thereof.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3) The act of May 18, 1976 (P.L.123, No.54), known as the Individual Accident and Sickness Insurance Minimum Standards Act.

(4) Chapter 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).

"Reimbursement."Payments made to a health care provider by an insurer.

"Waste."The overutilization of professional medical services or the misuse of resources by a health care provider.