Terms Used In South Carolina Code > Title 38 > Chapter 59 - Claims Practices

• Affirmed: In the practice of the appellate courts, the decree or order is declared valid and will stand as rendered in the lower court.
• APA: means the American Pyrotechnics Association. See South Carolina Code 40-56-20
• 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.
• 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}
• Board: means the State Board of Pyrotechnic Safety. See South Carolina Code 40-56-20
• Casualty insurance: means each insurance against legal liability of the insured for bodily injury to or death of another person, including workers' compensation insurance, and for damages to or loss or destruction of the property of another person; medical payments insurance when written in conjunction with insurance covering liability for the deaths or bodily injuries of another person; guaranteeing the fidelity of a person holding a position of public or private trust; loss of or damage to property caused by burglary, theft, larceny, robbery, fraud, or unlawful taking or secretion of property owned by or entrusted to the insured; loss of or damage to property of the insured resulting from the explosion of or damage to a fired or unfired boiler or other pressure vessel, engine, turbine, compressor, pump, wheel, or an apparatus generating, transmitting, or using electric power, and machinery or equipment connected with any of them; loss resulting from nonpayment of debts owed to merchants or another person extending credit. See South Carolina Code 38-1-20
• Clean claim: means an eligible electronic or paper claim for reimbursement that:
  
  (a) is received by the insurer within one hundred twenty business days of the date the health care services at issue were performed;
  
  (b)(i) when submitted via paper has all the elements of the standardized CMS 1500 or UB 04 claim form, or the successor of each as either may be amended from time to time; or
  
  (ii) when submitted via an electronic transaction, uses only permitted standard code sets and has all the elements of the standard electronic formats as required by the Health Insurance Portability and Accountability Act of 1996 and other federal and state regulatory authority;
  
  (c) is for health care services covered by the health insurance plan and rendered to an insured person by a provider eligible for reimbursement under the health insurance plan;
  
  (d) has any corresponding referral that may be required for the applicable claim;
  
  (e) is a claim for which the insurer is the primary payor, or for which the insurer's responsibility as a secondary payor has been clearly established;
  
  (f) has no material defect, error, or impropriety that would affect the adjudication of the claim;
  
  (g) includes all required substantiating documentation or coding;
  
  (h) is not subject to any particular circumstance that the insurer reasonably believes, subject to review by the Department of Insurance, would prevent accurate or timely payment from being made on the claim under the terms of the health insurance plan, the participating provider agreement, or the insurer's published filing requirements; and
  
  (i) is under a health insurance plan for which the insurer has been timely paid all applicable premiums. See South Carolina Code 38-59-210
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Consumer fireworks: means any small firework device designed to produce visible effects by combustion and which must comply with the construction, chemical composition, and labeling regulations of the U. See South Carolina Code 40-56-20
• Contract: A legal written agreement that becomes binding when signed.
• Conviction: A judgement of guilt against a criminal defendant.
• 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.
• Dealer: means any person, corporation, or partnership who buys precious metal or precious or semiprecious stones or gems from the general public, whether in bulk or in manufactured form, with an intent to obtain a monetary profit for himself or for a principal. See South Carolina Code 40-54-10
• Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
• Department: means the Department of Labor, Licensing and Regulation;
  
  (5) "Director" means the Director of the Department of Labor, Licensing and Regulation or the director's official designee;
  
  (6) "Licensee" means a person granted an authorization to practice pursuant to this article and refers to a person holding a license, permit, certification, or registration granted pursuant to this article;
  
  (7) "Licensing act" means the individual statute or regulations, or both, of each regulated profession or occupation which include, but are not limited to, board governance, the qualifications and requirements for authorization to practice, prohibitions, and disciplinary procedures;
  
  (8) "Person" means an individual, partnership, or corporation;
  
  (9) "Profession" or "occupation" means a profession or occupation regulated or administered, or both, by the department pursuant to this article. See South Carolina Code 40-1-20
• Department: means the Department of Labor, Licensing and Regulation. See South Carolina Code 40-56-20
• Department: means the Department of Insurance of South Carolina. See South Carolina Code 38-1-20
• Director: means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the department. See South Carolina Code 38-1-20
• Display fireworks: means large fireworks designed primarily to produce visible or audible effects by combustion, deflagration, or detonation. See South Carolina Code 40-56-20
• 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}
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• 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.
• Fair market value: The price at which an asset would change hands in a transaction between a willing, informed buyer and a willing, informed seller.
• Fireworks: means any composition or device designed to produce a visible or an audible effect by combustion, deflagration, or detonation, and which meets the definition of "consumer fireworks" or "display fireworks" as defined by this section. See South Carolina Code 40-56-20
• Force majeure: means any act of God, governmental act, act of terrorism, war, fire, flood, earthquake, hurricane, or other natural disaster, explosion or civil commotion. See South Carolina Code 38-59-210
• Fraud: Intentional deception resulting in injury to another.
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health care services: means services included in furnishing an individual medical care or hospitalization, or services incident to the furnishing of medical care or hospitalization, and other services to prevent, alleviate, cure, or heal human illness, injury, or physical disability. See South Carolina Code 38-59-210
• Health insurance plan: means a health insurance policy or health benefit plan offered by a health insurer or a health maintenance organization that provides health insurance coverage, as defined in § 38-71-670(6). See South Carolina Code 38-59-210
• Health maintenance organization: means an organization as defined in § 38-33-20(8). See South Carolina Code 38-59-210
• insurance: includes annuities. See South Carolina Code 38-1-20
• Insurer: includes a corporation, fraternal organization, burial association, other association, partnership, society, order, individual, or aggregation of individuals engaging or proposing or attempting to engage as principals in any kind of insurance or surety business, including the exchanging of reciprocal or interinsurance contracts between individuals, partnerships, and corporations. See South Carolina Code 38-1-20
• Insurer: means an insurance company, a health maintenance organization, and any other entity providing health insurance coverage, as defined in § 38-71-670(6), which is licensed to engage in the business of insurance in this State and which is subject to state insurance regulation. See South Carolina Code 38-59-210
• 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}
• Legal tender: coins, dollar bills, or other currency issued by a government as official money. ^{Source: U.S. Mint}
• Local law enforcement agency: means the chief of police for businesses located within the corporate limits of a municipality and the county law enforcement agency for businesses located outside the corporate limits of a municipality. See South Carolina Code 40-54-10
• Marine insurance: means each insurance against loss or destruction of or damage to aircraft, vessels, or watercraft and their cargoes; insurance covering the risks or perils of navigation, transit, or transportation of all forms of property, including the liability of a carrier for hire for the loss of property of shippers delivered for transporting; marine builder's risks; bridges, tunnels, piers, wharves, docks and slips, dry docks, marine railways, and other aids to navigation and transportation, precious stones, precious metals, and jewelry, whether in the course of transportation or otherwise; coverage of personal property by all risk forms known as the "Personal Property Floater"; and coverage of mobile machinery and equipment. See South Carolina Code 38-1-20
• 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 provides covered health care services to an insured or a member pursuant to a contract with an insurer or health insurance plan. See South Carolina Code 38-59-210
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Permanent place of business: means a fixed premises either owned by the dealer or leased by him. See South Carolina Code 40-54-10
• Person: means a corporation, agency, partnership, association, voluntary organization, individual, or another entity, organization, or aggregation of individuals. See South Carolina Code 38-1-20
• Physician: means a doctor of medicine or doctor of osteopathic medicine licensed by the South Carolina Board of Medical Examiners. See South Carolina Code 38-59-210
• Policy: means a contract of insurance. See South Carolina Code 38-1-20
• Precious metal: means any article made in whole or in part of gold, silver, or platinum. See South Carolina Code 40-54-10
• Property insurance: means each insurance against direct or indirect loss of or damage to a property resulting from fire, smoke, weather disturbances, climatic conditions, earthquake, volcanic eruption, rising waters, insects, blight, animals, war damage, riot, civil commotion, destruction by order of civil authority to prevent spread of conflagration or for other reason, water damage, vandalism, glass breakage, explosion of a water system, collision, theft of automobiles, and personal effects in them (but no other forms of theft insurance), loss of or damage to domestic or wild animals, and any other perils to property which in the discretion of the director or his designee form proper subjects of property insurance, if not specified in items (1), (7), (11), (35), (40), (54), or (59) of this section. See South Carolina Code 38-1-20
• Provider: means a physician, hospital, or other person properly licensed, certified, or permitted, where required, to furnish health care services. See South Carolina Code 38-59-210
• Purchase: means the acquisition, including by means of being pawned to a dealer, of precious metal or precious or semiprecious stones or gems or both precious metal and precious or semiprecious stones or gems for a consideration of cash, goods, or other precious metals or precious or semiprecious stones or gems or both precious metals and precious or semiprecious stones or gems. See South Carolina Code 40-54-10
• Pyrotechnics: means any composition or device designed to produce visible or audible effects for entertainment purposes by combustion, deflagration, or detonation. See South Carolina Code 40-56-20
• 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.
• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• Surety: includes insurance or a bond that covers obligations to pay the debts, or answer for the default, of another, including faithlessness in a position of public or private trust. See South Carolina Code 38-1-20
• Title insurance: means insurance of the owners of real property and other persons lawfully interested in the title insurance against loss by reason of defective titles and undisclosed liens and encumbrances affecting the property. See South Carolina Code 38-1-20
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.