Terms Used In Indiana Code > Title 4 > Article 32.3 > Chapter 5 - Conduct of Allowable Activities

• administrator: means the entity that contracts with the department to create, operate, and maintain the data base. See Indiana Code 27-1-44.5-0.2
• administrator: has the meaning in Indiana Code 27-1-44.6-1
• adverse determination: means a denial of a request for benefits on the grounds that the health service or item:

  Indiana Code 27-1-37.5-1.5

• advisory board: means the all payer claims data base advisory board established under Indiana Code 27-1-44.5-0.4
• advisory board: refers to the all payer claims data base advisory board established under section 5 of this chapter. See Indiana Code 27-1-44.6-2
• affiliate: has the meaning set forth in IC 27-1-25-1. See Indiana Code 27-1-37.3-2
• affiliate: means a company that controls, is controlled by, or is under common control with another company. See Indiana Code 27-1-38-1
• Affirmed: In the practice of the appellate courts, the decree or order is declared valid and will stand as rendered in the lower court.
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• ancillary protection product: includes the following:

  Indiana Code 27-1-43.2-1

• Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
• articles of incorporation: includes both the original articles of incorporation and any and all amendments thereto, except where the original articles of incorporation only are expressly referred to, and includes articles of merger, consolidation and reinsurance, and in case of corporations, heretofore organized, articles of reorganization filed in the office of the secretary of state, and all amendments thereto. See Indiana Code 27-1-2-3
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Attorney: includes a counselor or other person authorized to appear and represent a party in an action or special proceeding. See Indiana Code 1-1-4-5
• capital: means the aggregate amount paid in on the shares of capital stock of a corporation issued and outstanding. See Indiana Code 27-1-2-3
• capitated rate reimbursement arrangement: means a fixed amount of money per patient per unit of time paid in advance to the health care provider for the delivery of health care services. See Indiana Code 27-1-37.6-2
• certificate: means a document issued to an individual group member as evidence of the group member's coverage under a master group insurance policy. See Indiana Code 27-1-41-1
• certificate of authority: means an instrument in writing issued by the department to an insurer, which sets out the authority of such insurer to engage in the business of insurance or activities connected therewith. See Indiana Code 27-1-2-3
• certificate of insurance: means a document prepared by an insurer or insurance producer as evidence of property or casualty insurance coverage. See Indiana Code 27-1-42-2
• Charity: An agency, institution, or organization in existence and operating for the benefit of an indefinite number of persons and conducted for educational, religious, scientific, medical, or other beneficent purposes.
• clinical peer: means a practitioner or other health care provider who either:

  Indiana Code 27-1-37.5-1.7

• commissioner: means the insurance commissioner appointed under IC 27-1-1-2. See Indiana Code 27-1-39-1
• commissioner: refers to the insurance commissioner appointed under IC 27-1-1-2. See Indiana Code 27-1-42-3
• Commissioner: means the "insurance commissioner" of this state. See Indiana Code 27-1-2-3
• consortium: refers to a self-insurance consortium established under section 7 of this chapter. See Indiana Code 27-1-39-2
• Contract: A legal written agreement that becomes binding when signed.
• contractor: refers to a person with a primary business purpose of entering into health care contracts with providers. See Indiana Code 27-1-37.3-3
• Conviction: A judgement of guilt against a criminal defendant.
• 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.
• corporation: means an insurance company and includes all persons, partnerships, corporations, associations, orders or societies engaged in or proposing to engage in making any kind of insurance authorized by the laws of this state. See Indiana Code 27-1-2-3
• covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 27-1-37.3-4
• covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 27-1-37.4-1
• covered individual: means an individual who is covered under a health plan. See Indiana Code 27-1-37.5-2
• covered individual: means an individual who is entitled to be provided health care services at a cost established according to a network plan. See Indiana Code 27-1-45-1
• covered individual: means an individual who is entitled to be provided health care services according to a health carrier's network plan. See Indiana Code 27-1-46-1
• covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 27-1-48-1
• covered individual: means an individual who is entitled to health insurance coverage. See Indiana Code 27-1-49-1
• CPT code: refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. See Indiana Code 27-1-37.5-3
• CPT code: refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. See Indiana Code 27-1-48-2
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• data base: refers to the all payer claims data base created under this chapter. See Indiana Code 27-1-44.5-1
• data base: refers to the all payer claims data base established under Indiana Code 27-1-44.6-3
• defined cost sharing: means a deductible payment or coinsurance amount imposed on a covered individual for a covered prescription drug under the covered individual's health insurance coverage. See Indiana Code 27-1-49-2
• department: refers to the department of insurance created by IC 27-1-1-1. See Indiana Code 27-1-39-3
• department: refers to the department of insurance created by IC 27-1-1-1. See Indiana Code 27-1-42-4
• Department: means "the department of insurance" of this state. See Indiana Code 27-1-2-3
• Dependent: A person dependent for support upon another.
• depository institution: means a depository financial institution (as defined in IC 28-9-2-6). See Indiana Code 27-1-38-3
• downside risk: means the risk borne by health care providers in a situation in which, if the total cost of care exceeds projected or budgeted costs, the health care providers will be responsible for a defined percentage of the amount by which the total cost of care exceeds the projected or budgeted costs. See Indiana Code 27-1-37.6-3
• Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) ^{Source: OCC}
• electronic medical records access agreement: means an agreement between a health plan and health care provider that:

  Indiana Code 27-1-37.6-5

• electronically delivered: includes the following:

  Indiana Code 27-1-43-1

• emergency services: means services that are:

  Indiana Code 27-1-45-1.5

• episode of care: means the medical care ordered to be provided for a specific medical procedure, condition, or illness. See Indiana Code 27-1-46-1.5
• 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.
• executive director: means the individual who is responsible for overseeing the operations of the data base as an employee of the department. See Indiana Code 27-1-44.5-1.2
• executive director: has the meaning in Indiana Code 27-1-44.6-4
• facility: means an institution in which health care services are provided to individuals. See Indiana Code 27-1-45-2
• Fair market value: The price at which an asset would change hands in a transaction between a willing, informed buyer and a willing, informed seller.
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• fixed fee schedule: means a total listing of fees used by a health plan to reimburse health care providers or facilities whether:

  Indiana Code 27-1-37.6-6

• Fraud: Intentional deception resulting in injury to another.
• Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
• good faith estimate: means a reasonable estimate of the price each provider anticipates charging for an episode of care for nonemergency health care services that:

  Indiana Code 27-1-46-2

• governmental hospital: means an acute care hospital licensed under IC 16-21-2 that is governed by:

  Indiana Code 27-1-47.5-1

• group: means the following:

  Indiana Code 27-1-41-2

• group administrator: means the officers or directors of a group or any other person legally vested with the responsibility to manage the affairs of a group. See Indiana Code 27-1-41-3
• group insurance policy: means a policy of insurance that provides personal excess liability insurance or personal umbrella liability insurance to participating group members under one (1) master policy:

  Indiana Code 27-1-41-4

• health benefit plan: means coverage for health care services provided under:

  Indiana Code 27-1-37.2-1

• health care contract: means a contract between a person and a provider specifying the rights and responsibilities of the:

  Indiana Code 27-1-37.3-6

• health care provider: means an individual or entity that is:

  Indiana Code 27-1-37.6-7

• health care service: means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider's license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products. See Indiana Code 27-1-37.5-4
• health care service: means a medical or surgical service for the diagnosis, prevention, treatment, cure, or relief of illness, injury, or disease that is measured at the diagnosis and procedure level for an individual health care provider. See Indiana Code 27-1-37.6-8
• health care service: means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider's license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products. See Indiana Code 27-1-48-3
• health carrier: means an entity:

  Indiana Code 27-1-46-3

• health insurance coverage: includes :

  Indiana Code 27-1-49-3

• health insurance educator: refers to the health insurance educator appointed under section 6 of this chapter. See Indiana Code 27-1-37.2-3
• health maintenance organization: means a person that undertakes to provide or arrange for the delivery of health care services to individuals on a prepaid basis, except for the individual's responsibility for copayments or deductibles. See Indiana Code 27-1-37.1-1
• health payer: includes the following:

  Indiana Code 27-1-44.5-2

• health plan: means a plan through which coverage is provided for health care services through insurance, prepayment, reimbursement, or otherwise. See Indiana Code 27-1-37.3-5
• health plan: means any of the following that provides coverage for prescription drugs:

  Indiana Code 27-1-37.4-2

• health plan: means any of the following that provides coverage for health care services:

  Indiana Code 27-1-37.5-5

• health plan: means any of the following:

  Indiana Code 27-1-37.6-9

• health plan: means any of the following that provides coverage for health care services:

  Indiana Code 27-1-48-4

• health provider contract: means an agreement with a provider relating to terms and conditions of reimbursement for health care services provided to an individual under:

  Indiana Code 27-1-37.1-2

• holder: means a person who is entitled to services or indemnification under a service contract. See Indiana Code 27-1-43.2-2
• in network: when used in reference to a provider, means that the health care services provided by the provider are subject to a health carrier's network plan. See Indiana Code 27-1-46-4
• in network provider: means a provider that is required under a network plan to provide health care services to covered individuals at not more than a preestablished rate or amount of compensation. See Indiana Code 27-1-45-3
• in writing: include printing, lithographing, or other mode of representing words and letters. See Indiana Code 1-1-4-5
• Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. ^{Source: FDIC}
• independent hospital: means a private nonprofit acute care hospital licensed under IC 16-21-2 that meets the following criteria:

  Indiana Code 27-1-47.5-2

• independent postsecondary educational institution: refers to an independent, degree granting college or university that is:

  Indiana Code 27-1-39-4

• Indiana nonprofit hospital system: means a hospital that:

  Indiana Code 27-1-47.5-3

• Insurance: means a contract of insurance or an agreement by which one (1) party, for a consideration, promises to pay money or its equivalent or to do an act valuable to the insured upon the destruction, loss or injury of something in which the other party has a pecuniary interest, or in consideration of a price paid, adequate to the risk, becomes security to the other against loss by certain specified risks; to grant indemnity or security against loss for a consideration. See Indiana Code 27-1-2-3
• insurance producer: has the meaning set forth in Indiana Code 27-1-42-5
• insurer: refers to an insurer (as defined in IC 27-1-2-3) that issues a policy of property or casualty insurance. See Indiana Code 27-1-42-6
• insurer: means a company, firm, partnership, association, order, society or system making any kind or kinds of insurance and shall include associations operating as Lloyds, reciprocal or inter-insurers, or individual underwriters. See Indiana Code 27-1-2-3
• insurer: means an insurer that provides health insurance coverage to a covered individual. See Indiana Code 27-1-49-4
• IPEP: refers to the Indiana Public Employers' Plan, Inc. See Indiana Code 27-1-45.5-1
• Judgment: means all final orders, decrees, and determinations in an action and all orders upon which executions may issue. See Indiana Code 1-1-4-5
• 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.
• Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). ^{Source: OCC}
• Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
• medical record: means written or printed information possessed by a provider (as defined in Ind. See Indiana Code 1-1-4-5
• member: means an independent postsecondary educational institution that enters into an agreement under section 7 of this chapter to form a consortium. See Indiana Code 27-1-39-5
• member: means one who holds a contract of insurance or is insured in an insurance company other than a stock corporation. See Indiana Code 27-1-2-3
• Minority leader: See Floor Leaders
• Month: means a calendar month, unless otherwise expressed. See Indiana Code 1-1-4-5
• motor vehicle: has the meaning set forth in IC 9-13-2-105(a). See Indiana Code 27-1-43.2-4
• network: means a group of provider facilities and practitioners that:

  Indiana Code 27-1-46-5

• network plan: means a plan under which providers are required by contract to provide health care services to covered individuals at not more than a preestablished rate or amount of compensation. See Indiana Code 27-1-45-4
• network plan: means a plan of a health carrier that:

  Indiana Code 27-1-46-6

• Nolo contendere: No contest-has the same effect as a plea of guilty, as far as the criminal sentence is concerned, but may not be considered as an admission of guilt for any other purpose.
• nonemergency health care service: means a discrete service or series of services ordered by a practitioner for an episode of care for the purpose of:

  Indiana Code 27-1-46-7

• Oath: includes "affirmation" and "to swear" includes to "affirm". See Indiana Code 1-1-4-5
• Oath: A promise to tell the truth.
• 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: refers to the following:

  Indiana Code 27-1-37.5-6

• participating provider: refers to the following:

  Indiana Code 27-1-48-5

• 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.
• party: means a recipient of a notice or document required as part of an insurance transaction. See Indiana Code 27-1-43-2
• patient service revenue: includes similar terms, including net patient service revenue and patient care service revenue. See Indiana Code 27-1-47.5-3
• pay for performance arrangement: means a reimbursement model that reimburses health care providers for meeting predefined targets as defined in the agreement for quality indicators or efficacy parameters to increase the quality or efficacy of care. See Indiana Code 27-1-37.6-11
• person: means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity that enters into a health provider contract with a provider. See Indiana Code 27-1-37.1-3
• person: has the meaning set forth in IC 27-1-2-3. See Indiana Code 27-1-42-7
• person: includes individuals, corporations, associations, and partnerships; personal pronoun includes all genders; the singular includes the plural and the plural includes the singular. See Indiana Code 27-1-2-3
• Plea: In a criminal case, the defendant's statement pleading "guilty" or "not guilty" in answer to the charges, a declaration made in open court.
• policyholder: means one who is a holder of a contract of insurance in an insurance company. See Indiana Code 27-1-2-3
• position: means the position of health insurance educator established under section 5 of this chapter. See Indiana Code 27-1-37.2-4
• practitioner: means the following:

  Indiana Code 27-1-45-5

• practitioner: means :

  Indiana Code 27-1-46-8

• Precedent: A court decision in an earlier case with facts and law similar to a dispute currently before a court. Precedent will ordinarily govern the decision of a later similar case, unless a party can show that it was wrongly decided or that it differed in some significant way.
• premium: means money or any other thing of value paid or given in consideration to an insurer, insurance producer, or solicitor on account of or in connection with a contract of insurance and shall include as a part but not in limitation of the above, policy fees, admission fees, membership fees and regular or special assessments and payments made on account of annuities. See Indiana Code 27-1-2-3
• President pro tempore: A constitutionally recognized officer of the Senate who presides over the chamber in the absence of the Vice President. The President Pro Tempore (or, "president for a time") is elected by the Senate and is, by custom, the Senator of the majority party with the longest record of continuous service.
• price: means the negotiated rate between the:

  Indiana Code 27-1-46-8.5

• prices: means allowables that are paid for patient care services. See Indiana Code 27-1-47.5-4
• principal office: means that office maintained by the corporation in this state, the address of which is required by the provisions of this article to be kept on file in the office of the department. See Indiana Code 27-1-2-3
• prior authorization: includes a health plan requirement that a prescription drug be authorized for payment by the health plan before the prescription drug is provided to a particular covered individual. See Indiana Code 27-1-37.4-3
• prior authorization: means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. See Indiana Code 27-1-37.5-7
• prior authorization: means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. See Indiana Code 27-1-37.6-12
• prior authorization: means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. See Indiana Code 27-1-48-6
• Property: includes personal and real property. See Indiana Code 1-1-4-5
• property and casualty insurance: means one (1) or more of the types of insurance described in IC 27-1-5-1, Class 2 and Class 3. See Indiana Code 27-1-44-1
• property or casualty insurance: means one (1) or more of the kinds of insurance described in Class 2 and Class 3 of IC 27-1-5-1. See Indiana Code 27-1-42-8
• provider: means :

  Indiana Code 27-1-37.1-4

• provider: means a person who is contractually obligated to a holder under a service contract. See Indiana Code 27-1-43.2-5
• provider: means :

  Indiana Code 27-1-45-6

• provider: means :

  Indiana Code 27-1-46-9

• provider facility: means any of the following:

  Indiana Code 27-1-46-10

• provider organization: means an entity that serves beneficiaries on a risk basis through a network of employed or affiliated providers. See Indiana Code 27-1-37.6-13
• Quorum: The number of legislators that must be present to do business.
• rebate: means :

  Indiana Code 27-1-49-6

• Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
• self-insurance fund: means a fund established by a consortium to provide money sufficient to:

  Indiana Code 27-1-39-6

• service contract: means an agreement:

  Indiana Code 27-1-43.2-7

• service contract reimbursement policy: means a policy of insurance that provides coverage for one (1) of the following:

  Indiana Code 27-1-43.2-8

• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• Statute: A law passed by a legislature.
• Trust account: A general term that covers all types of accounts in a trust department, such as estates, guardianships, and agencies. ^{Source: OCC}
• Trustee: A person or institution holding and administering property in trust.
• trusteed surplus: means the aggregate value of a United States branch's:

  Indiana Code 27-1-40-1

• United States: includes the District of Columbia and the commonwealths, possessions, states in free association with the United States, and the territories. See Indiana Code 1-1-4-5
• United States branch: means :

  Indiana Code 27-1-40-2

• urgent care facility: means a freestanding health care facility that offers episodic, walk-in care for the treatment of acute, but not life threatening, health conditions. See Indiana Code 27-1-46-10.5
• urgent care situation: means a situation in which a covered individual's treating physician has determined that the covered individual's condition is likely to result in:

  Indiana Code 27-1-37.5-8

• Verified: when applied to pleadings, means supported by oath or affirmation in writing. See Indiana Code 1-1-4-5
• warranty: means a guarantee that:

  Indiana Code 27-1-43.2-9

• Year: means a calendar year, unless otherwise expressed. See Indiana Code 1-1-4-5