354.600. Definitions.

371 words·~2 min read·/mo/chapter-354/354-600

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354.600. Definitions. — For purposes of sections 354.600 to 354.636 the following terms shall mean:

(1)"Facility" , 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 facilities, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

(2)"Health benefit plan" , 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;

(3)"Health care professional" , a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services;

(4)"Health care provider" or "provider" , a health care professional or a facility;

(5)"Health carrier" , a health maintenance organization established pursuant to sections 354.400 to 354.636 ;

(6)"Health indemnity plan" , a health benefit plan that is not a managed care plan;

(7)"Intermediary" , a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network;

(8)"Managed care plan" , a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use health care providers managed, owned, under contract with or employed by the health carrier;

(9)"Network" , the group of participating providers providing services to a managed care plan;

(10)"Participating provider" , a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the health carrier;

(11)"Primary care professional" or "primary care provider" , a participating health care professional designated by the health carrier to supervise, coordinate or provide initial care or continuing care to an enrollee, 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 enrollee.

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(L. 1997 H.B. 335, A.L. 2007 S.B. 66)