Ohio § 3963.01

§ 3963.01.

As used in this chapter: (A) “ Affiliate ” means any person or entity that has ownership or control of a contracting entity,

is owned or controlled by a contracting entity, or is under common ownership or control

with a contracting entity. (B) “Basic health care services” has the same meaning as in division (A) of section 1751.01 of the Revised Code , except that it does not include any services listed in that division that are provided

by a pharmacist or nursing home. (C) “ Covered vision services ” means vision care services or vision care materials for which a reimbursement is

available under an enrollee's health care contract, or for which a reimbursement would

be available but for the application of contractual limitations, such as a deductible,

copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitation,

alternative benefit payment, or any other limitation. (D) “ Contracting entity ” means any person that has a primary business purpose of contracting with participating

providers for the delivery of health care services. (E) “ Covered dental services ” means dental care services for which reimbursement is available under an enrollee's

health care contract, or for which a reimbursement would be available but for the

application of contractual limitations, such as a deductible, copayment, coinsurance,

waiting period, annual or lifetime maximum, frequency limitation, alternative benefit

payment, or any other limitation. (F) “ Credentialing ” means the process of assessing and validating the qualifications of a provider applying

to be approved by a contracting entity to provide basic health care services, specialty

health care services, or supplemental health care services to enrollees. (G) “ Dental care provider ” means a dentist licensed under Chapter 4715. of the Revised Code.  “Dental care provider” does not include a dental hygienist licensed under Chapter

4715. of the Revised Code. (H) “ Edit ” means adjusting one or more procedure codes billed by a participating provider on

a claim for payment or a practice that results in any of the following: (1) Payment for some, but not all of the procedure codes originally billed by a participating

provider; (2) Payment for a different procedure code than the procedure code originally billed

by a participating provider; (3) A reduced payment as a result of services provided to an enrollee that are claimed

under more than one procedure code on the same service date. (I) “ Electronic claims transport ” means to accept and digitize claims or to accept claims already digitized, to place

those claims into a format that complies with the electronic transaction standards

issued by the United States department of health and human services pursuant to the

“Health Insurance Portability and Accountability Act of 1996,” 110 Stat. 1955, 42 U.S.C. 1320d, et seq., as those electronic standards are applicable to the parties and as those electronic

standards are updated from time to time, and to electronically transmit those claims

to the appropriate contracting entity, payer, or third-party administrator. (J) “ Enrollee ” means any person eligible for health care benefits under a health benefit plan,

including an eligible recipient of medicaid, and includes all of the following terms: (1) “Enrollee” and “subscriber” as defined by section 1751.01 of the Revised Code ; (2) “Member” as defined by section 1739.01 of the Revised Code ; (3) “Insured” and “plan member” pursuant to Chapter 3923. of the Revised Code; (4) “Beneficiary” as defined by section 3901.38 of the Revised Code . (K) “ Health care contract ” means a contract entered into, materially amended, or renewed between a contracting

entity and a participating provider for the delivery of basic health care services,

specialty health care services, or supplemental health care services to enrollees. (L) “ Health care services ” means basic health care services, specialty health care services, and supplemental

health care services. (M) “ Material amendment ” means an amendment to a health care contract that decreases the participating provider's

payment or compensation, changes the administrative procedures in a way that may reasonably

be expected to significantly increase the provider's administrative expenses, or adds

a new product.  A material amendment does not include any of the following: (1) A decrease in payment or compensation resulting solely from a change in a published

fee schedule upon which the payment or compensation is based and the date of applicability

is clearly identified in the contract; (2) A decrease in payment or compensation that was anticipated under the terms of the

contract, if the amount and date of applicability of the decrease is clearly identified

in the contract; (3) An administrative change that may significantly increase the provider's administrative

expense, the specific applicability of which is clearly identified in the contract; (4) Changes to an existing prior authorization, precertification, notification, or referral

program that do not substantially increase the provider's administrative expense; (5) Changes to an edit program or to specific edits if the participating provider is

provided notice of the changes pursuant to division (A)(1) of section 3963.04 of the Revised Code and the notice includes information sufficient for the provider to determine the

effect of the change; (6) Changes to a health care contract described in division (B) of section 3963.04 of the Revised Code . (N) “ Participating provider ” means a provider that has a health care contract with a contracting entity and is

entitled to reimbursement for health care services rendered to an enrollee under the

health care contract. (O) “ Payer ” means any person that assumes the financial risk for the payment of claims under

a health care contract or the reimbursement for health care services provided to enrollees

by participating providers pursuant to a health care contract. (P) “ Primary enrollee ” means a person who is responsible for making payments for participation in a health

care plan or an enrollee whose employment or other status is the basis of eligibility

for enrollment in a health care plan. (Q) “ Procedure codes ” includes the American medical association's current procedural terminology code,

the American dental association's current dental terminology, and the centers for

medicare and medicaid services health care common procedure coding system. (R) “ Product ” means 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: (1) A health maintenance organization or other product provided by a health insuring

corporation; (2) A preferred provider organization; (3) Medicare; (4) Medicaid; (5) Workers' compensation. (S) “ Provider ” means a physician, podiatrist, dentist, chiropractor, optometrist, psychologist,

physician assistant, advanced practice registered nurse, occupational therapist, massage

therapist, physical therapist, licensed professional counselor, licensed professional

clinical counselor, hearing aid dealer, orthotist, prosthetist, home health agency,

hospice care program, pediatric respite care program, or hospital, or a provider organization

or physician-hospital organization that is acting exclusively as an administrator

on behalf of a provider to facilitate the provider's participation in health care

contracts. “ Provider ” does not mean either of the following: (1) A nursing home; (2) A provider organization or physician-hospital organization that leases the provider

organization's or physician-hospital organization's network to a third party or contracts

directly with employers or health and welfare funds. (T) “Specialty health care services” has the same meaning as in section 1751.01 of the Revised Code , except that it does not include any services listed in division (B) of section 1751.01 of the Revised Code that are provided by a pharmacist or a nursing home. (U) “Supplemental health care services” has the same meaning as in division (B) of section 1751.01 of the Revised Code , except that it does not include any services listed in that division that are provided

by a pharmacist or nursing home. (V) “ Vision care materials ” includes lenses, devices containing lenses, prisms, lens treatments and coatings,

contact lenses, orthopics, vision training, and any prosthetic device necessary to

correct, relieve, or treat any defect or abnormal condition of the human eye or its

adnexa. (W) “ Vision care provider ” means either of the following: (1) An optometrist licensed under Chapter 4725. of the Revised Code; (2) A physician authorized under Chapter 4731. of the Revised Code to practice medicine

and surgery or osteopathic medicine and surgery.