Terms Used In West Virginia Code > Chapter 33 > Article 45 - Ethics and Fairness in Insurer Business Practices

• 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.
• Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
• Claim: means each individual request for reimbursement or proof of loss made by or on behalf of an insured or a provider to an insurer, or its intermediary, administrator or representative, with which the provider has a provider contract for payment for health care services under any health plan. See West Virginia Code 33-45-1
• Clean claim: means a claim:

  (A) That has no material defect or impropriety, including all reasonably required information and substantiating documentation, to determine eligibility or to adjudicate the claim. See West Virginia Code 33-45-1

• Commissioner: means the Insurance Commissioner of West Virginia. See West Virginia Code 33-45-1
• Contract: A legal written agreement that becomes binding when signed.
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• 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.
• Health care services: means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical or mental disability. See West Virginia Code 33-45-1
• Health plan: means any individual or group health care plan, subscription contract, evidence of coverage, certificate, health services plan. See West Virginia Code 33-45-1
• in writing: includes any representation of words, letters, or figures, whether by printing, engraving, writing, or otherwise. See West Virginia Code 2-2-10
• Insured: means a person who is provided health insurance coverage or other health care services coverage from an insurer under a health plan. See West Virginia Code 33-45-1
• Insurer: means any person required to be licensed under this chapter which offers or administers as a third party administrator health insurance. See West Virginia Code 33-45-1
• Intermediary: means a physician, hospital, physician-hospital organization, independent provider organization, or independent provider network which receives compensation for arranging one or more health care services to be rendered by providers to insureds of a health plan or insurer. See West Virginia Code 33-45-1
• 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.
• Provider: means a person or other entity which holds a valid license or permit, including a valid temporary license or permit pursuant to chapter 30 of this code, to provide specific health care services in this state. See West Virginia Code 33-45-1
• Provider contract: means any contract between a provider and

  (A) An insurer. See West Virginia Code 33-45-1

• Retroactive denial: means the practice of denying previously paid claims by withholding or setting off against payments, or in any other manner reducing or affecting the future claim payments to the provider, or to seek direct cash reimbursement from a provider for a payment previously made to the provider. See West Virginia Code 33-45-1
• State: when applied to a part of the United States and not restricted by the context, includes the District of Columbia and the several territories, and the words "United States" also include the said district and territories. See West Virginia Code 2-2-10