Terms Used In Utah Code > Title 31A > Chapter 45 - Managed Care Organizations

• Abuse of authority: means an arbitrary or capricious exercise of power that:
       (1)(a) adversely affects the employment rights of another; or
       (1)(b) results in personal gain to the person exercising the authority or to another person. See Utah Code 67-21-2
• Accident and health insurance: means insurance to provide protection against economic losses resulting from:
            (1)(a)(i) a medical condition including:

                 (1)(a)(i)(A) a medical care expense; or

                 (1)(a)(i)(B) the risk of disability;
            (1)(a)(ii) accident; or
            (1)(a)(iii) sickness. See Utah Code 31A-1-301
• Administrator: means the same as that term is defined in Subsection (187). See Utah Code 31A-1-301
• Administrator: includes "executor" when the subject matter justifies the use. See Utah Code 68-3-12.5
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Agency: means :
       (6)(a) a person other than an individual, including a sole proprietorship by which an individual does business under an assumed name; and
       (6)(b) an insurance organization licensed or required to be licensed under Section 31A-23a-301, 31A-25-207, or 31A-26-209. See Utah Code 31A-1-301
• Allegation: something that someone says happened.
• 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.
• Application: means a document:
       (10)(a)

            (10)(a)(i) completed by an applicant to provide information about the risk to be insured; and

            (10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:

                 (10)(a)(ii)(A) insure the risk under:

                      (10)(a)(ii)(A)(I) the coverage as originally offered; or

                      (10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or

                 (10)(a)(ii)(B) decline to insure the risk; or
       (10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
• benefit: means the health care services to which a covered person is entitled under the terms of a health care insurance plan offered by a managed care organization. See Utah Code 31A-45-102
• board of directors: means the group of persons with responsibility over, or management of, a corporation, however designated. See Utah Code 31A-1-301
• City: includes , depending on population, a metro township as defined in Section 10-3c-102. See Utah Code 68-3-12.5
• 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.
• 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.
• County utility easement: means an easement that:
       (11)(a) a plat recorded in a county recorder's office described as a county utility easement or otherwise as a utility easement;
       (11)(b) is not a protected utility easement or a public utility easement as defined in Section 54-3-27;
       (11)(c) the county or the county's affiliated governmental entity owns or creates; and
       (11)(d)

            (11)(d)(i) either:

                 (11)(d)(i)(A) no person uses or occupies; or

                 (11)(d)(i)(B) the county or the county's affiliated governmental entity uses and occupies to provide a utility service, including sanitary sewer, culinary water, electrical, storm water, or communications or data lines; or

            (11)(d)(ii) a person uses or occupies with or without an authorized franchise or other agreement with the county. See Utah Code 17-27a-103
• Culinary water authority: means the department, agency, or public entity with responsibility to review and approve the feasibility of the culinary water system and sources for the subject property. See Utah Code 17-27a-103
• Damages: means general and special damages for injury or loss caused by each violation of this chapter. See Utah Code 67-21-2
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Deed: The legal instrument used to transfer title in real property from one person to another.
• Department: means the Insurance Department. See Utah Code 31A-1-301
• Development activity: means :
       (13)(a) any construction or expansion of a building, structure, or use that creates additional demand and need for public facilities;
       (13)(b) any change in use of a building or structure that creates additional demand and need for public facilities; or
       (13)(c) any change in the use of land that creates additional demand and need for public facilities. See Utah Code 17-27a-103
• Development agreement: means a written agreement or amendment to a written agreement between a county and one or more parties that regulates or controls the use or development of a specific area of land. See Utah Code 17-27a-103
• Director: means a member of the board of directors of a corporation. See Utah Code 31A-1-301
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Employee: means a person who performs a service for wages or other remuneration under a contract of hire, written or oral, express or implied. See Utah Code 67-21-2
• Employer: includes an agent of an employer. See Utah Code 67-21-2
• Enrollee: includes an insured. See Utah Code 31A-1-301
• Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
• Equal: means , with respect to biological sex, of the same value. See Utah Code 68-3-12.5
• 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.
• Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following:
       (67)(a) a specific physical condition;
       (67)(b) a specific medical procedure;
       (67)(c) a specific disease or disorder; or
       (67)(d) a specific prescription drug or class of prescription drugs. See Utah Code 31A-1-301
• Filed: means that a filing is:
            (69)(a)(i) submitted to the department as required by and in accordance with applicable statute, rule, or filing order;
            (69)(a)(ii) received by the department within the time period provided in applicable statute, rule, or filing order; and
            (69)(a)(iii) accompanied by the appropriate fee in accordance with:

                 (69)(a)(iii)(A) Section 31A-3-103; or

                 (69)(a)(iii)(B) rule. See Utah Code 31A-1-301
• Filing: when used as a noun, means an item required to be filed with the department including:
       (70)(a) a policy;
       (70)(b) a rate;
       (70)(c) a form;
       (70)(d) a document;
       (70)(e) a plan;
       (70)(f) a manual;
       (70)(g) an application;
       (70)(h) a report;
       (70)(i) a certificate;
       (70)(j) an endorsement;
       (70)(k) an actuarial certification;
       (70)(l) a licensee annual statement;
       (70)(m) a licensee renewal application;
       (70)(n) an advertisement;
       (70)(o) a binder; or
       (70)(p) an outline of coverage. See Utah Code 31A-1-301
• General plan: means a document that a county adopts that sets forth general guidelines for proposed future development of:
       (20)(a) the unincorporated land within the county; or
       (20)(b) for a mountainous planning district, the land within the mountainous planning district. See Utah Code 17-27a-103
• Good faith: means that an employee acts with:
       (6)(a) subjective good faith; and
       (6)(b) the objective good faith of a reasonable employee. See Utah Code 67-21-2
• Gross mismanagement: means action or failure to act by a person, with respect to a person's responsibility, that causes significant harm or risk of harm to the mission of the public entity or public body that employs, or is managed or controlled by, the person. See Utah Code 67-21-2
• Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
• Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
       (83)(a) a professional service;
       (83)(b) a personal service;
       (83)(c) a facility;
       (83)(d) equipment;
       (83)(e) a device;
       (83)(f) supplies; or
       (83)(g) medicine. See Utah Code 31A-1-301
• Health care provider: means the same as that term is defined in Section 78B-3-403. See Utah Code 31A-1-301
• health insurance: means insurance providing:
            (84)(a)(i) a health care benefit; or
            (84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301
• Improvement completion assurance: means a surety bond, letter of credit, financial institution bond, cash, assignment of rights, lien, or other equivalent security required by a county to guaranty the proper completion of landscaping or an infrastructure improvement required as a condition precedent to:
       (26)(a) recording a subdivision plat; or
       (26)(b) development of a commercial, industrial, mixed use, or multifamily project. See Utah Code 17-27a-103
• Improvement warranty: means an applicant's unconditional warranty that the applicant's installed and accepted landscaping or infrastructure improvement:
       (27)(a) complies with the county's written standards for design, materials, and workmanship; and
       (27)(b) will not fail in any material respect, as a result of poor workmanship or materials, within the improvement warranty period. See Utah Code 17-27a-103
• Improvement warranty period: means a period:
       (28)(a) no later than one year after a county's acceptance of required landscaping; or
       (28)(b) no later than one year after a county's acceptance of required infrastructure, unless the county:

            (28)(b)(i) determines for good cause that a one-year period would be inadequate to protect the public health, safety, and welfare; and

            (28)(b)(ii) has substantial evidence, on record:

                 (28)(b)(ii)(A) of prior poor performance by the applicant; or

                 (28)(b)(ii)(B) that the area upon which the infrastructure will be constructed contains suspect soil and the county has not otherwise required the applicant to mitigate the suspect soil. See Utah Code 17-27a-103
• Individual: means a natural person. See Utah Code 31A-1-301
• Infrastructure improvement: means permanent infrastructure that is essential for the public health and safety or that:
       (29)(a) is required for human consumption; and
       (29)(b) an applicant must install:

            (29)(b)(i) in accordance with published installation and inspection specifications for public improvements; and

            (29)(b)(ii) as a condition of:

                 (29)(b)(ii)(A) recording a subdivision plat;

                 (29)(b)(ii)(B) obtaining a building permit; or

                 (29)(b)(ii)(C) developing a commercial, industrial, mixed use, condominium, or multifamily project. See Utah Code 17-27a-103
• insolvent: means that:
       (95)(a) an insurer is unable to pay the insurer's obligations as the obligations are due;
       (95)(b) an insurer's total adjusted capital is less than the insurer's mandatory control level RBC under Subsection 31A-17-601(8)(c); or
       (95)(c) an insurer's admitted assets are less than the insurer's liabilities. See Utah Code 31A-1-301
• Insurance: includes :
            (96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
            (96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
            (96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
• Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
            (103)(a)(i) a policyholder;
            (103)(a)(ii) a subscriber;
            (103)(a)(iii) a member; and
            (103)(a)(iv) a beneficiary. See Utah Code 31A-1-301
• Judicial employee: means an employee of the judicial branch of state government. See Utah Code 67-21-2
• Land: includes :
       (18)(a) land;
       (18)(b) a tenement;
       (18)(c) a hereditament;
       (18)(d) a water right;
       (18)(e) a possessory right; and
       (18)(f) a claim. See Utah Code 68-3-12.5
• Land use authority: means :
       (35)(a) a person, board, commission, agency, or body, including the local legislative body, designated by the local legislative body to act upon a land use application; or
       (35)(b) if the local legislative body has not designated a person, board, commission, agency, or body, the local legislative body. See Utah Code 17-27a-103
• Land use decision: means an administrative decision of a land use authority or appeal authority regarding:
       (36)(a) a land use permit;
       (36)(b) a land use application; or
       (36)(c) the enforcement of a land use regulation, land use permit, or development agreement. See Utah Code 17-27a-103
• 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}
• Legislative: when used to describe the powers, duties, or functions of a county commission or council, refers to:
       (3)(a) the power and duty to enact ordinances, levy taxes, and establish budgets; and
       (3)(b) those powers, duties, and functions that, under constitutional and statutory provisions and through long usage and accepted practice and custom at the federal and state level, have come to be regarded as belonging to the legislative branch of government. See Utah Code 17-50-101
• Legislative employee: means an employee of the legislative branch of state government. See Utah Code 67-21-2
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• Lot: means a tract of land, regardless of any label, that is created by and shown on a subdivision plat that has been recorded in the office of the county recorder. See Utah Code 17-27a-103
• Managed care organization: means :
       (2)(a) a managed care organization as that term is defined in Section 31A-1-301; and
       (2)(b) a third party administrator as that term is defined in Section 31A-1-301. See Utah Code 31A-45-102
• Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301
• Mountainous planning district: means an area designated by a county legislative body in accordance with Section 17-27a-901. See Utah Code 17-27a-103
• Mutual: means a mutual insurance corporation. See Utah Code 31A-1-301
• Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
• Order: means an order of the commissioner. See Utah Code 31A-1-301
• Parcel: means any real property that is not a lot. See Utah Code 17-27a-103
• Person: means :
       (24)(a) an individual;
       (24)(b) an association;
       (24)(c) an institution;
       (24)(d) a corporation;
       (24)(e) a company;
       (24)(f) a trust;
       (24)(g) a limited liability company;
       (24)(h) a partnership;
       (24)(i) a political subdivision;
       (24)(j) a government office, department, division, bureau, or other body of government; and
       (24)(k) any other organization or entity. See Utah Code 68-3-12.5
• Person: includes :
       (146)(a) an individual;
       (146)(b) a partnership;
       (146)(c) a corporation;
       (146)(d) an incorporated or unincorporated association;
       (146)(e) a joint stock company;
       (146)(f) a trust;
       (146)(g) a limited liability company;
       (146)(h) a reciprocal;
       (146)(i) a syndicate; or
       (146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
• Person: means an individual, corporation, partnership, organization, association, trust, governmental agency, or any other legal entity. See Utah Code 17-27a-103
• Plat: means an instrument subdividing property into lots as depicted on a map or other graphical representation of lands that a licensed professional land surveyor makes and prepares in accordance with Section 17-27a-603 or 57-8-13. See Utah Code 17-27a-103
• Policy: includes a service contract issued by:
            (150)(b)(i) a motor club under Chapter 11, Motor Clubs;
            (150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and
            (150)(b)(iii) a corporation licensed under:

                 (150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or

                 (150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301
• Political subdivision employee: means an employee of a political subdivision of the state. See Utah Code 67-21-2
• PPACA: means the Patient Protection and Affordable Care Act, Pub. See Utah Code 31A-1-301
• Premium: includes , however designated:
            (156)(b)(i) an assessment;
            (156)(b)(ii) a membership fee;
            (156)(b)(iii) a required contribution; or
            (156)(b)(iv) monetary consideration. See Utah Code 31A-1-301
• Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
• Proceeding: includes an action or special statutory proceeding. See Utah Code 31A-1-301
• Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
• Property: includes both real and personal property. See Utah Code 68-3-12.5
• Public body: means any of the following:
       (11)(a) a state officer, employee, agency, department, division, bureau, board, commission, council, authority, educational institution, or any other body in the executive branch of state government;
       (11)(b) an agency, board, commission, council, institution member, or employee of the legislative branch of state government;
       (11)(c) a county, city, town, regional governing body, council, school district, special district, special service district, or municipal corporation, board, department, commission, council, agency, or any member or employee of them;
       (11)(d) any other body that is created by state or local authority, or that is primarily funded by or through state or local authority, or any member or employee of that body;
       (11)(e) a law enforcement agency or any member or employee of a law enforcement agency; and
       (11)(f) the judiciary and any member or employee of the judiciary. See Utah Code 67-21-2
• Public entity: means a department, division, board, council, committee, institution, office, bureau, or other similar administrative unit of the executive branch of state government. See Utah Code 67-21-2
• Public entity employee: means an employee of a public entity. See Utah Code 67-21-2
• Public street: means a public right-of-way, including a public highway, public avenue, public boulevard, public parkway, public road, public lane, public alley, public viaduct, public subway, public tunnel, public bridge, public byway, other public transportation easement, or other public way. See Utah Code 17-27a-103
• Rate: means :
            (163)(a)(i) the cost of a given unit of insurance; or
            (163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:

                 (163)(a)(ii)(A) a single number; or

                 (163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:

                      (163)(a)(ii)(B)(I) expenses;

                      (163)(a)(ii)(B)(II) profit; and

                      (163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Retaliatory action: means the same as that term is defined in Section 67-19a-101. See Utah Code 67-21-2
• Road: includes :
       (33)(a) a public bridge;
       (33)(b) a county way;
       (33)(c) a county road;
       (33)(d) a common road; and
       (33)(e) a state road. See Utah Code 68-3-12.5
• Sanitary sewer authority: means the department, agency, or public entity with responsibility to review and approve the feasibility of sanitary sewer services or onsite wastewater systems. See Utah Code 17-27a-103
• Security: means a:
            (176)(a)(i) note;
            (176)(a)(ii) stock;
            (176)(a)(iii) bond;
            (176)(a)(iv) debenture;
            (176)(a)(v) evidence of indebtedness;
            (176)(a)(vi) certificate of interest or participation in a profit-sharing agreement;
            (176)(a)(vii) collateral-trust certificate;
            (176)(a)(viii) preorganization certificate or subscription;
            (176)(a)(ix) transferable share;
            (176)(a)(x) investment contract;
            (176)(a)(xi) voting trust certificate;
            (176)(a)(xii) certificate of deposit for a security;
            (176)(a)(xiii) certificate of interest of participation in an oil, gas, or mining title or lease or in payments out of production under such a title or lease;
            (176)(a)(xiv) commodity contract or commodity option;
            (176)(a)(xv) certificate of interest or participation in, temporary or interim certificate for, receipt for, guarantee of, or warrant or right to subscribe to or purchase any of the items listed in Subsections (176)(a)(i) through (xiv); or
            (176)(a)(xvi) another interest or instrument commonly known as a security. See Utah Code 31A-1-301
• State: includes any department, division, or agency of the state. See Utah Code 17-27a-103
• State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
• State institution of higher education: means the same as that term is defined in Section 53B-3-102. See Utah Code 67-21-2
• Subdivision: includes :
            (73)(b)(i) the division or development of land, whether by deed, metes and bounds description, devise and testacy, map, plat, or other recorded instrument, regardless of whether the division includes all or a portion of a parcel or lot; and
            (73)(b)(ii) except as provided in Subsection (73)(c), divisions of land for residential and nonresidential uses, including land used or to be used for commercial, agricultural, and industrial purposes. See Utah Code 17-27a-103
• Town: includes , depending on population, a metro township as defined in Section 10-3c-102. See Utah Code 68-3-12.5
• Unethical conduct: means conduct that violates a provision of Title 67, Chapter 16, Utah Public Officers' and Employees' Ethics Act. See Utah Code 67-21-2
• Unincorporated: means the area outside of the incorporated area of a municipality. See Utah Code 17-27a-103
• United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
• Volunteer: includes a juror or potential juror appearing in response to a summons for a trial jury or grand jury. See Utah Code 67-20-2
• Volunteer search and rescue team member: means an individual who:
       (11)(a) provides services as a volunteer under the supervision of a county sheriff; and
       (11)(b) at the time the individual provides the services to the county sheriff described in Subsection (11)(a), is:

            (11)(b)(i) certified as a member of the county sheriff's search and rescue team; and

            (11)(b)(ii) acting in the capacity of a member of the search and rescue team of the supervising county sheriff. See Utah Code 67-20-2
• Writing: includes :
       (48)(a) printing;
       (48)(b) handwriting; and
       (48)(c) information stored in an electronic or other medium if the information is retrievable in a perceivable format. See Utah Code 68-3-12.5