Texas Insurance Code 1369.251 – Definitions
Terms Used In Texas Insurance Code 1369.251
- 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.
- 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.
- Written: includes any representation of words, letters, symbols, or figures. See Texas Government Code 311.005
In this subchapter:
(1) “Desk audit” means an audit conducted by a health benefit plan issuer or pharmacy benefit manager at a location other than the location of the pharmacist or pharmacy. The term includes an audit performed at the offices of the plan issuer or pharmacy benefit manager during which the pharmacist or pharmacy provides requested documents for review by hard copy or by microfiche, disk, or other electronic media. The term does not include a review conducted not later than the third business day after the date a claim is adjudicated provided recoupment is not demanded.
(2) “Extrapolation” means a mathematical process or technique used by a health benefit plan issuer or pharmacy benefit manager that administers pharmacy claims for a health benefit plan issuer in the audit of a pharmacy or pharmacist to estimate audit results or findings for a larger batch or group of claims not reviewed by the plan issuer or pharmacy benefit manager.
(3) “Health benefit plan” means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including:
(A) an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:
(i) an insurance company;
(ii) a group hospital service corporation operating under Chapter 842;
(iii) a health maintenance organization operating under Chapter 843;
(iv) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;
(v) a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;
(vi) a stipulated premium company operating under Chapter 884;
(vii) a fraternal benefit society operating under Chapter 885;
(viii) a Lloyd’s plan operating under Chapter 941; or
(ix) an exchange operating under Chapter 942;
(B) a small employer health benefit plan written under Chapter 1501; or
(C) a health benefit plan issued under Chapter 1551, 1575, 1579, or 1601.
(4) “On-site audit” means an audit that is conducted at:
(A) the location of the pharmacist or pharmacy; or
(B) another location at which the records under review are stored.
(5) “Pharmacy benefit manager” has the meaning assigned by § 4151.151.