(a) The following words and terms when used in this chapter have the following meanings unless the context clearly indicates otherwise.

(1) Administrator--Has the meaning assigned by Insurance Code §4151.001, concerning Definitions.

(2) Adverse determination--A determination by a URA made on behalf of a payor that the health care services provided or proposed to be provided to an injured employee are not medically necessary or appropriate. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review. For the purposes of this subchapter, an adverse determination does not include a determination that health care services are experimental or investigational.

(3) Affiliate--Has the meaning assigned by Insurance Code §1305.004, concerning Definitions.

(4) Capitation--Has the meaning assigned by Insurance Code §1305.004. The term includes predetermined payment to cover the average costs of services for a defined episode of care.

(5) Complainant--Has the meaning assigned by Insurance Code §1305.004.

(6) Complaint--Has the meaning assigned by Insurance Code §1305.004.

(7) Concurrent utilization review--A form of utilization review for ongoing health care or for an extension of treatment beyond previously approved health care.

(8) Credentialing--Has the meaning assigned by Insurance Code §1305.004.

(9) Division of Workers' Compensation--Has the meaning assigned to the "Division" by Labor Code §401.011, concerning General Definitions.

(10) Emergency--Has the meaning assigned by Insurance Code §1305.004.

(11) Employee--Has the meaning assigned by Labor Code §401.012, concerning Definition of Employee.

(12) Fee dispute--Has the meaning assigned by Insurance Code §1305.004.

(13) HMO--A health maintenance organization licensed and regulated under Insurance Code Chapter 843, concerning Health Maintenance Organizations.

(14) Independent review--Has the meaning assigned by Insurance Code §1305.004.

(15) Independent review organization--Has the meaning assigned by Insurance Code §1305.004.

(16) Life-threatening--Has the meaning assigned by Insurance Code Chapter 4201, concerning Utilization Review Agents.

(17) Live or lives--Where an employee lives includes: (A) the employee's principal residence for legal purposes, including the physical address that the employee represented to the employer as the employee's address; (B) a temporary residence necessitated by employment; or (C) a temporary residence taken by the employee primarily for the purpose of receiving necessary assistance with routine daily activities because of a compensable injury.

(18) MCQA--The Office of Managed Care Quality Assurance, or a successor office at the department.

(19) Medical emergency--Has the meaning assigned by Insurance Code §1305.004.

(20) Medical records--Has the meaning assigned by Insurance Code §1305.004.

(21) Mental health emergency--Has the meaning assigned by Insurance Code §1305.004.

(22) Network or workers' compensation health care network--Has the meaning assigned by Insurance Code §1305.004.

(23) Occupational medicine specialist--A doctor who has received a board certification in occupational medicine from the American Board of Preventive Medicine or who has completed all the requirements of the American Board of Preventive Medicine in order to take the board examination.

(24) Person--Has the meaning assigned by Insurance Code §1305.004.

(25) Physician--Has the meaning assigned by Insurance Code §4201.002, concerning Definitions.

(26) Preauthorization--A form of prospective utilization review by a payor or a payor's URA of health care services proposed to be provided to an injured employee.

(27) Provider--A health care provider.

(28) Quality improvement program--Has the meaning assigned by Insurance Code §1305.004.

(29) Retrospective review--A form of utilization review for health care services that have been provided to an injured employee. Retrospective review does not include review of services for which prospective or concurrent utilization reviews were previously conducted or should have been previously conducted.

(30) Routine daily activities""Activities a person normally does in daily living, including sleeping, eating, bathing, dressing, grooming, and homemaking.

(31) Rural area--Has the meaning assigned by Insurance Code §1305.004.

(32) Screening criteria--Has the meaning assigned by Insurance Code §1305.004.

(33) Service area--Has the meaning assigned by Insurance Code §1305.004.

(34) Telehealth service, telemedicine medical service, and teledentistry dental service--Have the meanings assigned by Occupations Code §111.001, concerning Definitions.

(35) Transfer of risk--Has the meaning assigned by Insurance Code §1305.004.

(36) Utilization review--Has the meaning assigned by Insurance Code Chapter 4201.

(37) Utilization review agent or URA--Has the meaning assigned by Insurance Code Chapter 4201.

(b) When used in this chapter, the following terms have the meanings assigned by Labor Code §401.011:

(1) administrative violation;

(2) case management;

(3) compensable injury;

(4) doctor;

(5) employer;

(6) evidence-based medicine;

(7) health care;

(8) health care facility;

(9) health care practitioner;

(10) health care provider;

(11) impairment rating;

(12) injury;

(13) insurance carrier;

(14) maximum medical improvement; and

(15) treating doctor.

Source Note: The provisions of this §10.2 adopted to be effective December 5, 2005, 30 TexReg 8099; amended to be effective August 2, 2022, 47 TexReg 4534