Terms Used In Utah Code > Title 31A > Chapter 45 > Part 3 - Relationships with Providers

• Abuse of authority: means an arbitrary or capricious exercise of power that:
       (1)(a) adversely affects the employment rights of another; or
       (1)(b) results in personal gain to the person exercising the authority or to another person. See Utah Code 67-21-2
• Administrator: includes "executor" when the subject matter justifies the use. See Utah Code 68-3-12.5
• Administrator: means the same as that term is defined in Subsection (187). See Utah Code 31A-1-301
• Allegation: something that someone says happened.
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Application: means a document:
       (10)(a)

            (10)(a)(i) completed by an applicant to provide information about the risk to be insured; and

            (10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:

                 (10)(a)(ii)(A) insure the risk under:

                      (10)(a)(ii)(A)(I) the coverage as originally offered; or

                      (10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or

                 (10)(a)(ii)(B) decline to insure the risk; or
       (10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
• benefit: means the health care services to which a covered person is entitled under the terms of a health care insurance plan offered by a managed care organization. See Utah Code 31A-45-102
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Contract: A legal written agreement that becomes binding when signed.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Damages: means general and special damages for injury or loss caused by each violation of this chapter. See Utah Code 67-21-2
• Department: means the Insurance Department. See Utah Code 31A-1-301
• Director: means a member of the board of directors of a corporation. See Utah Code 31A-1-301
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Employee: means a person who performs a service for wages or other remuneration under a contract of hire, written or oral, express or implied. See Utah Code 67-21-2
• Employer: includes an agent of an employer. See Utah Code 67-21-2
• Enrollee: includes an insured. See Utah Code 31A-1-301
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following:
       (67)(a) a specific physical condition;
       (67)(b) a specific medical procedure;
       (67)(c) a specific disease or disorder; or
       (67)(d) a specific prescription drug or class of prescription drugs. See Utah Code 31A-1-301
• Filed: means that a filing is:
            (69)(a)(i) submitted to the department as required by and in accordance with applicable statute, rule, or filing order;
            (69)(a)(ii) received by the department within the time period provided in applicable statute, rule, or filing order; and
            (69)(a)(iii) accompanied by the appropriate fee in accordance with:

                 (69)(a)(iii)(A) Section 31A-3-103; or

                 (69)(a)(iii)(B) rule. See Utah Code 31A-1-301
• Filing: when used as a noun, means an item required to be filed with the department including:
       (70)(a) a policy;
       (70)(b) a rate;
       (70)(c) a form;
       (70)(d) a document;
       (70)(e) a plan;
       (70)(f) a manual;
       (70)(g) an application;
       (70)(h) a report;
       (70)(i) a certificate;
       (70)(j) an endorsement;
       (70)(k) an actuarial certification;
       (70)(l) a licensee annual statement;
       (70)(m) a licensee renewal application;
       (70)(n) an advertisement;
       (70)(o) a binder; or
       (70)(p) an outline of coverage. See Utah Code 31A-1-301
• Good faith: means that an employee acts with:
       (6)(a) subjective good faith; and
       (6)(b) the objective good faith of a reasonable employee. See Utah Code 67-21-2
• Gross mismanagement: means action or failure to act by a person, with respect to a person's responsibility, that causes significant harm or risk of harm to the mission of the public entity or public body that employs, or is managed or controlled by, the person. See Utah Code 67-21-2
• Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
• Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
       (83)(a) a professional service;
       (83)(b) a personal service;
       (83)(c) a facility;
       (83)(d) equipment;
       (83)(e) a device;
       (83)(f) supplies; or
       (83)(g) medicine. See Utah Code 31A-1-301
• Health care provider: means the same as that term is defined in Section 78B-3-403. See Utah Code 31A-1-301
• Individual: means a natural person. See Utah Code 31A-1-301
• insolvent: means that:
       (95)(a) an insurer is unable to pay the insurer's obligations as the obligations are due;
       (95)(b) an insurer's total adjusted capital is less than the insurer's mandatory control level RBC under Subsection 31A-17-601(8)(c); or
       (95)(c) an insurer's admitted assets are less than the insurer's liabilities. See Utah Code 31A-1-301
• Insurance: includes :
            (96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
            (96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
            (96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
• Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
            (103)(a)(i) a policyholder;
            (103)(a)(ii) a subscriber;
            (103)(a)(iii) a member; and
            (103)(a)(iv) a beneficiary. See Utah Code 31A-1-301
• Judicial employee: means an employee of the judicial branch of state government. See Utah Code 67-21-2
• Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). ^{Source: OCC}
• Legislative employee: means an employee of the legislative branch of state government. See Utah Code 67-21-2
• Managed care organization: means :
       (2)(a) a managed care organization as that term is defined in Section 31A-1-301; and
       (2)(b) a third party administrator as that term is defined in Section 31A-1-301. See Utah Code 31A-45-102
• Mutual: means a mutual insurance corporation. See Utah Code 31A-1-301
• Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
• Person: includes :
       (146)(a) an individual;
       (146)(b) a partnership;
       (146)(c) a corporation;
       (146)(d) an incorporated or unincorporated association;
       (146)(e) a joint stock company;
       (146)(f) a trust;
       (146)(g) a limited liability company;
       (146)(h) a reciprocal;
       (146)(i) a syndicate; or
       (146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
• Person: means :
       (24)(a) an individual;
       (24)(b) an association;
       (24)(c) an institution;
       (24)(d) a corporation;
       (24)(e) a company;
       (24)(f) a trust;
       (24)(g) a limited liability company;
       (24)(h) a partnership;
       (24)(i) a political subdivision;
       (24)(j) a government office, department, division, bureau, or other body of government; and
       (24)(k) any other organization or entity. See Utah Code 68-3-12.5
• Political subdivision employee: means an employee of a political subdivision of the state. See Utah Code 67-21-2
• Premium: includes , however designated:
            (156)(b)(i) an assessment;
            (156)(b)(ii) a membership fee;
            (156)(b)(iii) a required contribution; or
            (156)(b)(iv) monetary consideration. See Utah Code 31A-1-301
• Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
• Proceeding: includes an action or special statutory proceeding. See Utah Code 31A-1-301
• Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
• Property: includes both real and personal property. See Utah Code 68-3-12.5
• Public body: means any of the following:
       (11)(a) a state officer, employee, agency, department, division, bureau, board, commission, council, authority, educational institution, or any other body in the executive branch of state government;
       (11)(b) an agency, board, commission, council, institution member, or employee of the legislative branch of state government;
       (11)(c) a county, city, town, regional governing body, council, school district, special district, special service district, or municipal corporation, board, department, commission, council, agency, or any member or employee of them;
       (11)(d) any other body that is created by state or local authority, or that is primarily funded by or through state or local authority, or any member or employee of that body;
       (11)(e) a law enforcement agency or any member or employee of a law enforcement agency; and
       (11)(f) the judiciary and any member or employee of the judiciary. See Utah Code 67-21-2
• Public entity: means a department, division, board, council, committee, institution, office, bureau, or other similar administrative unit of the executive branch of state government. See Utah Code 67-21-2
• Public entity employee: means an employee of a public entity. See Utah Code 67-21-2
• Rate: means :
            (163)(a)(i) the cost of a given unit of insurance; or
            (163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:

                 (163)(a)(ii)(A) a single number; or

                 (163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:

                      (163)(a)(ii)(B)(I) expenses;

                      (163)(a)(ii)(B)(II) profit; and

                      (163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301
• Retaliatory action: means the same as that term is defined in Section 67-19a-101. See Utah Code 67-21-2
• State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
• State institution of higher education: means the same as that term is defined in Section 53B-3-102. See Utah Code 67-21-2
• Unethical conduct: means conduct that violates a provision of Title 67, Chapter 16, Utah Public Officers' and Employees' Ethics Act. See Utah Code 67-21-2
• United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
• Writing: includes :
       (48)(a) printing;
       (48)(b) handwriting; and
       (48)(c) information stored in an electronic or other medium if the information is retrievable in a perceivable format. See Utah Code 68-3-12.5