Terms Used In Vermont Statutes > Title 18 > Chapter 221 > Subchapter 2 - Claims Processing and Contract Standards

• Affirmed: In the practice of the appellate courts, the decree or order is declared valid and will stand as rendered in the lower court.
• Agency: means the Agency of Transportation. See
• 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.
• 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.
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Attorney-in-fact: A person who, acting as an agent, is given written authorization by another person to transact business for him (her) out of court.
• 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 Green Mountain Care Board established in chapter 220 of this title. See
• Board: means the Transportation Board. See
• Branch: means a major component of a division of a department or major unit of a department with staff functions. See
• Claim: means any claim, bill, or request for payment for all or any portion of provided health care services that is submitted by:

• Commissioner: means the Commissioner of Financial Regulation or the Commissioner's designee. See
• Commissioner: means the Commissioner of Motor Vehicles responsible to the Secretary for the administration of the Department. See
• Contested claim: means a claim submitted to a payer, health plan, or contracting entity that does not include:

• Contract: A legal written agreement that becomes binding when signed.
• contract: means a contract entered into, amended, or renewed between a contracting entity or health plan and a health care provider specifying the rights and responsibilities of the contracting entity and provider for the delivery of health care services to insureds, including primary care health services, preventive health services, chronic care services, and specialty health care services. See
• Contracting entity: means any entity that contracts directly or indirectly with a health care provider for either the delivery of health care services or the selling, leasing, renting, assigning, or granting of access to a contract or terms of a contract. See
• 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 entity: means an organization that enters into a contract with a contracting entity to gain access to a provider network contract. See
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• denial: means the circumstance in which the plan asserts that it has no liability to pay a claim, based on eligibility status of the patient, coverage of a service under the health plan, medical necessity of a service, liability of another payer, or other grounds. See
• Department: means the Department of Motor Vehicles. See
• Department: means the Department of Financial Regulation. See
• Dependent: A person dependent for support upon another.
• Develop: means the partition or division of any tract of land of any size by a person through sale, lease, transfer, or any other means by which any interest in or to the land or a portion of the land is conveyed to another person that will require the construction of permanent new or enlarged points of access to a State or town highway other than a limited access facility pursuant to subsection 1702a(a) of this title; excluding, however, tracts of land located entirely within a city or incorporated village. See
• District: means a geographic subdivision of the State primarily established for maintenance purposes. See
• Division: means a major unit of the Agency engaged in line functions other than the Department of Motor Vehicles. See
• editing: means a practice or procedure pursuant to which one or more adjustments are made to Current Procedural Terminology (CPT) codes, American Society of Anesthesiologists' (ASA) current procedural terminology, the American Dental Association's (ADA) current dental terminology, or Healthcare Common Procedure Coding System (HCPCS) Level II codes included in a claim that result in:

• 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}
• 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.
• Escrow: Money given to a third party to be held for payment until certain conditions are met.
• 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.
• Executor: A male person named in a will to carry out the decedent
• 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.
• Fees: shall mean earnings due for official services, aside from salaries or per diem compensation. See
• Fiduciary: A trustee, executor, or administrator.
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• following: when used by way of reference to a section of the law shall mean the next preceding or following section. See
• Fraud: Intentional deception resulting in injury to another.
• Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
• Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. ^{Source: Federal Reserve}
• 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 facility: means all institutions, whether public or private, proprietary or nonprofit, which offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. See
• Health care provider: means a person, partnership, or corporation, other than a facility or institution, licensed or certified or authorized by law to provide professional health care service in this State to an individual during that individual's medical care, treatment, or confinement. See
• Health insurer: means any health insurance company, nonprofit hospital and medical service corporation, managed care organizations, and, to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by public and private entities. See
• Health maintenance organization: means any person certified to operate a health maintenance organization by the Commissioner pursuant to 8 Vt. See
• Health plan: means a health insurer, disability insurer, health maintenance organization, medical or hospital service corporation, and, to the extent permitted under federal law, any administrator of an insured or self-insured plan. See
• highway: includes rights-of-way, bridges, drainage structures, signs, guardrails, areas to accommodate utilities authorized by law to locate within highway limits, areas used to mitigate the environmental impacts of highway construction, vegetation, scenic enhancements, and structures. See
• Hospital: means an acute care hospital licensed under chapter 43 of this title. See
• Insured: means any person eligible for health care benefits under a health benefit plan, and includes all of the following terms: enrollee, subscriber, member, insured, dependent, covered individual, and beneficiary. See
• 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.
• 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}
• Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
• Managed care organization: means any financing mechanism or system that manages health care delivery for its members or subscribers, including health maintenance organizations and any other similar health care delivery system or organization. See
• Most favored nation clause: means a provision in a health care contract that:

• Municipality: shall include a city, town, town school district, incorporated school or fire district or incorporated village, and all other governmental incorporated units. See
• NCCI: means the Centers for Medicare and Medicaid Services' (CMS) published list of edits and adjustments that are made to health care providers' claims submitted for services or supplies provided to patients insured under the federal Medicare program and other federal insurance programs. See
• 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.
• Oversight: Committee review of the activities of a Federal agency or program.
• Participating provider: means a health care provider that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an insured under the health care contract. See
• 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.
• Payer: means any person or entity that assumes the financial risk for the payment of claims under a health care contract or the reimbursement for health care services rendered to an insured by a participating provider under the health care contract. See
• Permit: means any permit or license issued pursuant to this title. See
• Person: means any individual, company, corporation, association, partnership, the U. See
• Precedent: A court decision in an earlier case with facts and law similar to a dispute currently before a court. Precedent will ordinarily govern the decision of a later similar case, unless a party can show that it was wrongly decided or that it differed in some significant way.
• prior authorization: includes preadmission review, pretreatment review, and utilization review. See
• Product: means , to the extent permitted by State and federal law, 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:

• provider: means a person, partnership, or corporation licensed, certified, or otherwise authorized by law to provide professional health care services in this State and shall include a health care provider group, network, independent practice association, or physician hospital organization that is acting exclusively as an administrator on behalf of a health care provider to facilitate the provider's participation in health care contracts. See
• Secretary: means the head of the Agency who shall be a member of the Governor's Cabinet responsible directly to the Governor for the administration of the Agency. See
• 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.
• State: when applied to the different parts of the United States may apply to the District of Columbia and any territory and the Commonwealth of Puerto Rico. See
• submitting party: means :

• Testify: Answer questions in court.
• Town: includes incorporated villages and cities. See