Idaho Code 41-5601 – Definitions
Current as of: 2023 | Check for updates
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As used in this chapter:
(1) "Beneficiary" means a policyholder, subscriber, member, employer or other person who is eligible for benefits under a contract providing hospital, surgical, or medical expense coverage or a managed care organization policy or agreement under which a third party payer agrees to reimburse for covered health care services rendered to beneficiaries in accordance with the benefits contract.
Terms Used In Idaho Code 41-5601
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Beneficiary: means a policyholder, subscriber, member, employer or other person who is eligible for benefits under a contract providing hospital, surgical, or medical expense coverage or a managed care organization policy or agreement under which a third party payer agrees to reimburse for covered health care services rendered to beneficiaries in accordance with the benefits contract. See Idaho Code 41-5601
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Department: means the department of insurance. See Idaho Code 41-5601
- Director: means the director of the department of insurance. See Idaho Code 41-5601
- Electronic claim: means a claim that is transmitted through the use of electronic media, which includes the internet, extranet, leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one (1) location to another using magnetic tape, disk or compact disk media. See Idaho Code 41-5601
- Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) Source: OCC
- Insurer: means any insurer that sells hospital, medical, long-term care, or vision insurance policies or certificates and managed care organizations. See Idaho Code 41-5601
- person: includes a corporation as well as a natural person;
Idaho Code 73-114Practitioner or facility: means any physician, hospital or other person or facility licensed or otherwise authorized to furnish health care services. See Idaho Code 41-5601
(2) "Date of payment" means the date the payment is sent as indicated by the mail stamp on the envelope, by the insurer to the practitioner or facility or to the beneficiary in the event there is not a contract for direct payment by the insurer to the practitioner or facility, or, in the event of a wire or other electronic funds transfer, upon acceptance by the insurer’s bank of a payment order.
(3) "Department" means the department of insurance.
(4) "Director" means the director of the department of insurance.
(5) "Electronic claim" means a claim that is transmitted through the use of electronic media, which includes the internet, extranet, leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one (1) location to another using magnetic tape, disk or compact disk media. The claim shall contain the proper format and code sets in accordance with the applicable implementation specifications under 45 C.F.R. § part 160 et seq., and 45 C.F.R. § part 162 et seq.
(6) "Insurer" means any insurer that sells hospital, medical, long-term care, or vision insurance policies or certificates and managed care organizations. For the purpose of this chapter only, "insurer" also includes a third party administrator who makes payments to beneficiaries, practitioners or facilities on behalf of an insurer and a hospital or professional service corporation that provides hospital, medical, long-term care or vision health care services.
(7) "Practitioner or facility" means any physician, hospital or other person or facility licensed or otherwise authorized to furnish health care services.
(8) "Receipt of claim" means the date the claim is actually received by the insurer from the practitioner or facility or the beneficiary.
(9) "Submission of claim" means the date the claim is sent as indicated by the mail stamp on the envelope, by the beneficiary, practitioner or facility, to the insurer or the date an electronic claim is transmitted to an insurer.