Section 27-65-1 Definitions.
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/al/title-27-insurance/chapter-65/27-65-1·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
For the purposes of this chapter, the following words have the following meanings:
(1)CLEAN CLAIM. A clean electronic claim or a clean written claim.
(2)CLEAN ELECTRONIC CLAIM. As defined in Section 27-1-17.
(3)CLEAN WRITTEN CLAIM. As defined in Section 27-1-17.
(4)COLLECTION. Any written or oral communication made to an enrollee for the purpose of obtaining payment for the services rendered by an emergency medical service provider, including invoicing and legal debt collection efforts.
(5)COST-SHARING AMOUNT. The enrollee’s deductible, coinsurance, copayment, or other amount due under a health care benefit plan for covered services.
(6)COVERED SERVICES or COVERED SERVICE. Transport or medical services provided by the ground ambulance of an emergency medical service provider which are covered by an enrollee’s health care benefit plan, which may include emergency ground transport and treat in place.
(7)EMERGENCY GROUND TRANSPORT. a. When an enrollee is transported by an emergency medical service provider to a hospital or definitive care facility as defined in Section 22-18-1, and which may include basic life support or advanced life support, in response to a medical condition described in paragraph b.
b. An event as defined by the Centers for Medicare and Medicaid Services
(CMS)which manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
1. Placing the patient’s health in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part.
(8)EMERGENCY MEDICAL SERVICE PROVIDER or PROVIDER. Any public or private organization that is licensed to provide emergency medical services as defined in Section 22-18-1.
(9)ENROLLEE. An individual who is covered by a health care benefit plan.
(10)HEALTH CARE BENEFIT PLAN. The term includes any individual or group plan, policy, or contract issued, delivered, or renewed in this state by a health care insurer to provide, deliver, arrange for, pay for, or reimburse health care services, including those provided by an emergency medical service provider, except for payments for health care made under an automobile or homeowners’ insurance plan, accident-only plan, specified disease plan, long-term care plan, supplemental hospital or fixed indemnity plan, dental or vision plan, or Medicaid.
(11)HEALTH CARE INSURER. Any entity that issues or administers a health care benefit plan, including a health care insurer, a health care services plan incorporated under Chapter 20 of Title 10A, a health maintenance organization established under Chapter 21A of Title 27, or a nonprofit agricultural organization that offers health benefits to its membership pursuant to Chapter 33 of Title 2.
(12)IN-NETWORK. When an emergency medical service provider is in a contract with a health care insurer to provide covered services in the health care insurer’s provider network.
(13)OUT-OF-NETWORK. When an emergency medical service provider does not have a contract with a health care insurer to provide covered services in the health care insurer’s provider network.
(14)TREAT IN PLACE. An emergency response event in which an emergency medical service provider that would otherwise provide the emergency ground transport assesses an enrollee and renders basic life support at his or her location without emergency ground transport.