Terms Used In Ohio Code > Chapter 3963 - Health Care Contracts

• Affiliate: means any person or entity that has ownership or control of a contracting entity, is owned or controlled by a contracting entity, or is under common ownership or control with a contracting entity. See Ohio Code 3963.01
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
• 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.
• Contracting entity: means any person that has a primary business purpose of contracting with participating providers for the delivery of health care services. See Ohio Code 3963.01
• 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.
• Covered vision services: means vision care services or vision care materials for which a reimbursement is available under an enrollee's health care contract, or for which a reimbursement would be available but for the application of contractual limitations such as a deductible, copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitation, alternative benefit payment, or any other limitation. See Ohio Code 3963.01
• Credentialing: means the process of assessing and validating the qualifications of a provider applying to be approved by a contracting entity to provide basic health care services, specialty health care services, or supplemental health care services to enrollees. See Ohio Code 3963.01
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Edit: means adjusting one or more procedure codes billed by a participating provider on a claim for payment or a practice that results in any of the following:

  (1) Payment for some, but not all of the procedure codes originally billed by a participating provider;

  (2) Payment for a different procedure code than the procedure code originally billed by a participating provider;

  (3) A reduced payment as a result of services provided to an enrollee that are claimed under more than one procedure code on the same service date. See Ohio Code 3963.01

• Electronic claims transport: means to accept and digitize claims or to accept claims already digitized, to place those claims into a format that complies with the electronic transaction standards issued by the United States department of health and human services pursuant to the "Health Insurance Portability and Accountability Act of 1996" 110 Stat. See Ohio Code 3963.01
• Enrollee: means any person eligible for health care benefits under a health benefit plan, including an eligible recipient of medicaid, and includes all of the following terms:

  (1) "Enrollee" and "subscriber" as defined by section 1751. See Ohio Code 3963.01

• Health care contract: means a contract entered into, materially amended, or renewed between a contracting entity and a participating provider for the delivery of basic health care services, specialty health care services, or supplemental health care services to enrollees. See Ohio Code 3963.01
• Health care services: means basic health care services, specialty health care services, and supplemental health care services. See Ohio Code 3963.01
• in writing: includes any representation of words, letters, symbols, or figures; this provision does not affect any law relating to signatures. See Ohio Code 1.59
• Material amendment: means an amendment to a health care contract that decreases the participating provider's payment or compensation, changes the administrative procedures in a way that may reasonably be expected to significantly increase the provider's administrative expenses, or adds a new product. See Ohio Code 3963.01
• Participating provider: means a provider that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an enrollee under the health care contract. See Ohio Code 3963.01
• Payer: means any person that assumes the financial risk for the payment of claims under a health care contract or the reimbursement for health care services provided to enrollees by participating providers pursuant to a health care contract. See Ohio Code 3963.01
• Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
• Physician assistant: means an individual who is licensed under Chapter 4730 of the Revised Code to provide services as a physician assistant to patients under the supervision, control, and direction of one or more physicians. See Ohio Code 1.64
• Procedure codes: includes the American medical association's current procedural terminology code, the American dental association's current dental terminology, and the centers for medicare and medicaid services health care common procedure coding system. See Ohio Code 3963.01
• Product: means one of the following types of categories of coverage for which a participating provider may be obligated to provide health care services pursuant to a health care contract:

  (1) A health maintenance organization or other product provided by a health insuring corporation;

  (2) A preferred provider organization;

  (3) Medicare;

  (4) Medicaid;

  (5) Workers' compensation. See Ohio Code 3963.01

• Provider: means a physician, podiatrist, pharmacist, dentist, chiropractor, optometrist, psychologist, physician assistant, advanced practice registered nurse, occupational therapist, massage therapist, physical therapist, licensed professional counselor, licensed professional clinical counselor, hearing aid dealer, orthotist, prosthetist, home health agency, hospice care program, pediatric respite care program, or hospital, or a provider organization or physician-hospital organization that is acting exclusively as an administrator on behalf of a provider to facilitate the provider's participation in health care contracts. See Ohio Code 3963.01
• Rule: includes regulation. See Ohio Code 1.59
• state: means the state of Ohio. See Ohio Code 1.59
• United States: includes all the states. See Ohio Code 1.59
• Vision care materials: includes lenses, devices containing lenses, prisms, lens treatments and coatings, contact lenses, orthopics, vision training, and any prosthetic device necessary to correct, relieve, or treat any defect or abnormal condition of the human eye or its adnexa. See Ohio Code 3963.01
• Vision care provider: means either of the following:

  (1) An optometrist licensed under Chapter 4725 of the Revised Code;

  (2) A physician authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery. See Ohio Code 3963.01