Pennsylvania § 4901 - Definitions.

§ 4901. Definitions.

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Covered person." A policyholder, subscriber or other individual who is entitled to receive health care services under a health insurance policy.

"Credit card payment." A type of electronic funds transfer in which a health insurer or its contracted vendor issues a single-use series of numbers associated with the payment of covered health care services performed by a health care provider and chargeable at a predetermined rate for which the health care provider is responsible for processing the payment by a credit card terminal or Internet portal. The term includes virtual or online credit card payments for which no physical card is presented to the health care provider and the single-use credit card expires upon payment processing.

"Dental insurance policy." An insurance policy that pays or provides dental expense benefits for covered dental services and is delivered or issued for delivery by or through a dental insurer. The term includes coverage for dental benefits issued either on a stand-alone basis or integrated, or otherwise incorporated into the terms and coverage of a health insurance policy.

"Dental insurer." An entity that offers, issues or renews a dental insurance policy that covers dental services provided by a dentist and that is governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3) Chapter 61 (relating to hospital plan corporations).

(4) Chapter 63 (relating to professional health services plan corporations).

"Dentist." A person licensed by the State Board of Dentistry to provide dental services. The term does not include a dental hygienist as defined in section 2 of the act of May 1, 1933 (P.L.216, No.76), known as The Dental Law.

"Electronic funds transfer." A payment of any method of electronic funds transfer as codified in 45 CFR 162.1601 (relating to health care electronic funds transfers (EFT) and remittance advice transaction) and 162.1602 (relating to standards for health care electronic funds transfers (EFT) and remittance advice transaction).

"Health care provider." A licensed hospital or health care facility, medical equipment supplier or person who is licensed, certified or otherwise regulated to provide health care services under the laws of this Commonwealth, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician's assistant, chiropractor, pharmacist, dentist or an individual accredited or certified to provide behavioral health services. The term includes an individual providing emergency services under a licensed emergency medical services agency as defined in 35 Pa.C.S. § 8103 (relating to definitions).

"Health care service." A covered treatment, admission, procedure, medical supplies and equipment or other service, including behavioral health, prescribed or otherwise provided or proposed to be provided by a health care provider to a covered person for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease under the terms of a health insurance policy.

"Health insurance policy." A policy, subscriber contract, certificate or plan issued by a health insurer that provides medical or health care coverage, including a dental insurance policy. The term does not include any of the following:

(1) An accident only policy.

(2) A credit only policy.

(3) A long-term care or disability income policy.

(4) A specified disease policy.

(5) A Medicare supplement policy.

(6) A TRICARE policy, including a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policy.

(7) A fixed indemnity policy.

(8) A hospital indemnity policy.

(9) A workers' compensation policy.

(10) An automobile medical payment policy under 75 Pa.C.S. (relating to vehicles).

(11) A homeowner's insurance policy.

(12) Any other similar policies providing for limited benefits.

"Health insurer." An entity, including a dental insurer, that offers, issues or renews a health insurance policy that is offered or governed under any of the following:

(1) The Insurance Company Law of 1921, including section 630 and Article XXIV.

(2) The Health Maintenance Organization Act.

(3) Chapter 61.

(4) Chapter 63.

"Merchant servicer." Any of the following, as defined in 26 U.S.C. § 6050W(b) (relating to returns relating to payments made in settlement of payment card and third party network transactions):

(1) A payment settlement entity.

(2) A merchant acquiring entity.

(3) A third-party settlement organization.

"Participating health care provider." A health care provider that has entered into a contractual or operating relationship with a health insurer to participate in one or more designated networks of the health insurer and to provide health care services to covered persons under the terms of the health insurer's administrative policy.