Terms Used In Hawaii Revised Statutes > Chapter 431 > Article 26 - Health Benefit Plan Network Access and Adequacy

• active course of treatment: includes treatment of a covered person on a regular basis by a provider being removed from or leaving the network. See Hawaii Revised Statutes 431:26-101
• Affordable Care Act: refers to the Patient Protection and Affordable Care Act (42 U. See Hawaii Revised Statutes 431:26-101
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Authorized representative: means :

  (1) A person to whom a covered person has given express written consent to represent the covered person;

  (2) A person authorized by law to provide substituted consent for a covered person; or

  (3) The covered person's treating health care professional only when the covered person or persons authorized pursuant to paragraphs (1) and (2) of this definition are unable to provide consent. See Hawaii Revised Statutes 431:26-101

• carrier: includes an accident and health or sickness insurer that issues health benefit plans under part I of article 10A of this chapter, a mutual benefit society under article 1 of chapter 432, and a health maintenance organization under chapter 432D. See Hawaii Revised Statutes 431:26-101
• Commissioner: means the insurance commissioner of the State. See Hawaii Revised Statutes 431:26-101
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Covered benefit: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Hawaii Revised Statutes 431:26-101
• Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan, offered or administered by a person or entity, including but not limited to an insurer governed by this chapter, a mutual benefit society governed by article 1 of chapter 432, and as a health maintenance organization governed by chapter 432D. See Hawaii Revised Statutes 431:26-101
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Facility: means an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic facilities, laboratories, and imaging centers, and rehabilitation and other therapeutic health settings licensed or certified by the department of health under chapter 321. See Hawaii Revised Statutes 431:26-101
• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered by, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services pursuant to chapter 87A, 431, 432, or 432D. See Hawaii Revised Statutes 431:26-101
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the practitioner's scope of practice under state law. See Hawaii Revised Statutes 431:26-101
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a physical, mental, or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders. See Hawaii Revised Statutes 431:26-101
• Intermediary: means a person authorized to negotiate and execute provider contracts with health carriers on behalf of health care providers or on behalf of a network, if applicable. See Hawaii Revised Statutes 431:26-101
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Network: means the group or groups of participating providers providing services under a network plan. See Hawaii Revised Statutes 431:26-101
• Network plan: means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, owned, under contract with, or employed by the health carrier. See Hawaii Revised Statutes 431:26-101
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Oversight: Committee review of the activities of a Federal agency or program.
• Participating provider: means a provider who, under a contract with the health carrier or with the health carrier's contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier. See Hawaii Revised Statutes 431:26-101
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Hawaii Revised Statutes 431:26-101
• Primary care: means health care services for a range of common conditions provided by a physician or nonphysician primary care professional. See Hawaii Revised Statutes 431:26-101
• Primary care professional: means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person, 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 covered person. See Hawaii Revised Statutes 431:26-101
• provider: means a health care professional, pharmacy, or facility. See Hawaii Revised Statutes 431:26-101
• Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
• Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. ^{Source: FDIC}
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Serious acute condition: means a disease or condition for which the covered person is currently requiring complex ongoing care, such as chemotherapy, post-operative visits, or radiation therapy. See Hawaii Revised Statutes 431:26-101
• Specialist: includes a subspecialist who has additional training and recognition above and beyond the subspecialist's specialty training. See Hawaii Revised Statutes 431:26-101
• Specialty care: means advanced medically necessary care and treatment of specific health conditions or health conditions that may manifest themselves in particular ages or subpopulations that are provided by a specialist, preferably in coordination with a primary care professional or other health care professional. See Hawaii Revised Statutes 431:26-101
• Telehealth: means health care services provided through telecommunications technology by a health care professional who is at a location other than where the covered person is located. See Hawaii Revised Statutes 431:26-101
• Tier: means specific groups of providers and facilities identified by a network and to which different provider reimbursement, covered person cost-sharing, provider access requirements, or any combination thereof, apply for the same services. See Hawaii Revised Statutes 431:26-101