Terms Used In Montana Code > Title 33 > Chapter 36 > Part 2 - Network Adequacy

• 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.
• Covered benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Montana Code 33-36-103
• Covered person: means a policyholder, subscriber, or enrollee or other individual participating in a health benefit plan. See Montana Code 33-36-103
• Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Montana Code 33-36-103
• 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.
• Facility: means an institution providing health care services or a health care setting, including but not limited to a hospital, medical assistance facility, critical access hospital, or rural emergency hospital, as those terms are defined in 50-5-101, or other licensed inpatient center, an outpatient center for surgical services, a treatment center, a skilled nursing center, a residential treatment center, a diagnostic laboratory, a diagnostic imaging center, or a rehabilitation or other therapeutic health setting. See Montana Code 33-36-103
• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-36-103
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified pursuant to the laws of this state to perform specified health care services consistent with state law. See Montana Code 33-36-103
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Montana Code 33-36-103
• Health carrier: means an entity subject to the insurance laws and rules of this state that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a disability insurer, health maintenance organization, or health service corporation or another entity providing a health benefit plan. See Montana Code 33-36-103
• Intermediary: means a person authorized to negotiate, execute, and be a party to a contract between a health carrier and a provider or between a health carrier and a network. See Montana Code 33-36-103
• Managed care plan: means a health benefit plan that either requires or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by a health carrier, but not preferred provider organizations or other provider networks operated in a fee-for-service indemnity environment. See Montana Code 33-36-103
• Medically necessary: means services, medicines, or supplies that are necessary and appropriate for the diagnosis or treatment of a covered person's illness, injury, or medical condition according to accepted standards of medical practice and that are not provided only as a convenience. See Montana Code 33-36-103
• Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Participating provider: means a provider who, under a contract with a health carrier or with the health carrier's contractor, subcontractor, or intermediary, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier. See Montana Code 33-36-103
• Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
• Primary care professional: means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person and who may be required by the health carrier to initiate a referral for specialty care and to maintain supervision of health care services rendered to the covered person. See Montana Code 33-36-103
• Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
• provider: means a health care professional or a facility. See Montana Code 33-36-103
• Quality assurance: means quality assessment and quality improvement. See Montana Code 33-36-103
• Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. ^{Source: FDIC}
• State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
• Writing: includes printing. See Montana Code 1-1-203