02-031-360 Me. Code R. § 3

Current through 2025-03, January 15, 2025

Section 031-360-3 - Definitions

A. "Administrator" means any person, other than a carrier, that administers a preferred provider arrangement.

B. "Copy" of any document to be filed with the Superintendent means a draft copy if a final copy is not reasonably available at the time of filing.

C. "Emergency services" means those health care services that are provided in an emergency facility or setting after the onset of an illness or medical condition that manifests itself by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected by the prudent lay person, who possesses an average knowledge of health and medicine, to result in:

(1) Serious jeopardy to the enrollee's physical and/or mental health;

(2) Serious impairment to bodily functions; or

(3) Serious dysfunction of any bodily organ or part.

D. "Health care services" means health care services or products rendered or sold by a provider within the scope of the provider's legal authorization.

E. "Health Maintenance Organization" means an organization of the kind defined at 24-A M.R.S.A. §4202-A(10).

F. "Medically necessary health care" means health care services or products provided to an enrollee for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease in a manner that is:

(1) Consistent with generally accepted standards of medical practice;

(2) Clinically appropriate in terms of type, frequency, extent, site, and duration;

(3) Demonstrated through scientific evidence to be effective in improving health outcomes;

(4) Representative of "best practices" in the medical profession; and

(5) Not primarily for the convenience of the enrollee or physician or other health practitioner.

G. "Preferred provider arrangement" means a contract, agreement, or arrangement between a carrier or administrator and a provider in which the provider agrees to provide services to a health plan enrollee whose plan benefits include incentives for the enrollee to use the services of that provider.

H. "Special condition" means a condition or disease that is life-threatening, degenerative, or disabling and requires specialized medical care over a prolonged period of time.

02-031 C.M.R. ch. 360, § 3