Terms Used In Rhode Island General Laws > Chapter 27-18.8 - Health Care Accessibility and Quality Assurance Act

• Adverse benefit determination: means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. See Rhode Island General Laws 27-18.8-2
• 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.
• Authorized representative: means an individual acting on behalf of the beneficiary and shall include: the ordering provider; any individual to whom the beneficiary has given express written consent to act on his or her behalf; a person authorized by law to provide substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the beneficiary. See Rhode Island General Laws 27-18.8-2
• 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 policy holder subscriber, enrollee, or other individual participating in a health benefit plan. See Rhode Island General Laws 27-18.8-2
• Benefit determination: means a decision to approve or deny a request to provide or make payment for a healthcare service. See Rhode Island General Laws 27-18.8-2
• Certificate: means a certificate granted by the commissioner to a healthcare entity meeting the requirements of this chapter. See Rhode Island General Laws 27-18.8-2
• Commissioner: means the commissioner of the office of the health insurance commissioner. See Rhode Island General Laws 27-18.8-2
• 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.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Delegate: means a person or entity authorized pursuant to a delegation of authority or directly or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or regulations or guidance promulgated thereunder. See Rhode Island General Laws 27-18.8-2
• health plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services. See Rhode Island General Laws 27-18.8-2
• Healthcare entity: means an insurance company licensed, or required to be licensed, by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing health insurance, accident and sickness insurance, health benefits, or healthcare services. See Rhode Island General Laws 27-18.8-2
• Healthcare services: means and includes, but is not limited to: an admission, diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care services, activities, or supplies that are covered by the beneficiary's health benefit plan. See Rhode Island General Laws 27-18.8-2
• in writing: include printing, engraving, lithographing, and photo-lithographing, and all other representations of words in letters of the usual form. See Rhode Island General Laws 43-3-16
• Judgement: The official decision of a court finally determining the respective rights and claims of the parties to a suit.
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Most-favored-rate clause: means a provision in a provider contract whereby the rates or fees to be paid by a healthcare entity are fixed, established, or adjusted to be equal to or lower than the rates or fees paid to the provider by any other healthcare entity. See Rhode Island General Laws 27-18.8-2
• Network: means the group or groups of participating providers providing healthcare services under a network plan. See Rhode Island General Laws 27-18.8-2
• Network plan: means a health benefit plan or health plan that either requires a beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the providers managed, owned, under contract with, or employed by the healthcare entity. See Rhode Island General Laws 27-18.8-2
• Office: means the office of the health insurance commissioner. See Rhode Island General Laws 27-18.8-2
• person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
• Professional provider: means an individual provider or healthcare professional licensed, accredited, or certified to perform specified healthcare services consistent with state law and who provides these healthcare services and is not part of a separate facility or institutional contract. See Rhode Island General Laws 27-18.8-2
• Provider: means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider, or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies. See Rhode Island General Laws 27-18.8-2
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• town: may be construed to include city; the words "town council" include city council; the words "town clerk" include city clerk; the words "ward clerk" include clerk of election district; the words "town treasurer" include city treasurer; and the words "town sergeant" include city sergeant. See Rhode Island General Laws 43-3-9
• Transcript: A written, word-for-word record of what was said, either in a proceeding such as a trial or during some other conversation, as in a transcript of a hearing or oral deposition.