Definitions

Definitions For purposes of this Regulation: A. “Commissioner” means the Commissioner of Insurance. B. “Covered benefits” or “benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan. C. “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. D. “Emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy. E. “Emergency services” means health care items and services furnished or required to evaluate and treat an emergency medical condition. F. “Facility” means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. G. “Health benefit plan” means a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services. H. “Health care professional” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law. I. “Health care provider” or “provider” means a health care professional or a facility. J. “Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. K. “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a third party administrator, a health maintenance organization, a nonprofit hospital, health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services. L. “Intermediary” means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network. M. “Managed care plan” means a plan as defined by Miss. Code Ann. § 83-41-403(b). N. “Network” means the group of participating providers providing services to a managed care plan and who have entered into a contract of reimbursement for benefits with a health carrier. O. “Participating provider” means a provider as defined by Miss. Code Ann. § 83-41- 403(e). P. “Person” means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. Q. “Primary care professional” means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.