Terms Used In Tennessee Code > Title 56 > Chapter 7 - Policies and Policyholders 33|373

• Abuse: means the knowing infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. See Tennessee Code 33-2-402
• Access Tennessee: means the nonprofit entity created pursuant to §. See Tennessee Code 56-7-2902
• Account owner: means the owner of a retained asset account who is a resident of this state. See Tennessee Code 56-7-3403
• Actual reimbursement: means the total amount that a covered entity or pharmacy benefits manager determines that a pharmacy or other dispenser will receive consistent with the provider agreement, and is the sum of the amount the covered entity or pharmacy benefits manager will pay directly to the pharmacy or other dispenser plus any applicable patient out-of-pocket cost paid directly by the patient to the pharmacy or other dispenser, for dispensing of a particular prescription or providing a covered service. See Tennessee Code 56-7-3201
• Actuarial certification: means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with §. See Tennessee Code 56-7-2203
• Additional business day: means the first weekday not designated as a state or federal holiday. See Tennessee Code 56-7-3702
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Alcohol and drug services: includes evaluation, treatment, residential personal care, habilitation, rehabilitation, counseling, or supervision of persons with substance use disorder, or services to persons designed to prevent substance use disorder that either receive funds from the department of health or assess fees for services provided. See Tennessee Code 33-2-402
• Allowed amount: means the contractually agreed upon payment amount between a carrier and a healthcare entity participating in the carrier's network, excluding any member deductible, co-pay, or other obligation. See Tennessee Code 56-7-602
• 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.
• 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.
• Annuity: means any active annuity contract issued in this state other than an annuity used to fund an employment-based retirement plan or program where the insurer is not committed by terms of the annuity contract to pay death benefits to the beneficiaries of specific plan participants or that is used to fund a pre-need funeral contract as defined in §. See Tennessee Code 56-7-3403
• Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
• 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.
• Applicant: means :
  (A) In the case of an individual medicare supplement policy, the person who seeks to contract for insurance benefits. See Tennessee Code 56-7-1501
• Appraisal: A determination of property value.
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Asymmetric conduct: means an insurer's use of the DMF prior to July 1, 2015, in connection with searching for information regarding whether annuitants under the insurer's annuities might be deceased, but not in connection with whether the insureds under its policies might be deceased. See Tennessee Code 56-7-3403
• Attorney: means the person designated and authorized by subscribers as the attorney-in-fact having authority to obligate them on reciprocal insurance contracts. See Tennessee Code 56-16-102
• Bail: Security given for the release of a criminal defendant or witness from legal custody (usually in the form of money) to secure his/her appearance on the day and time appointed.
• Bankruptcy: Refers to statutes and judicial proceedings involving persons or businesses that cannot pay their debts and seek the assistance of the court in getting a fresh start. Under the protection of the bankruptcy court, debtors may discharge their debts, perhaps by paying a portion of each debt. Bankruptcy judges preside over these proceedings.
• Base premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage. See Tennessee Code 56-7-2203
• Baseline: Projection of the receipts, outlays, and other budget amounts that would ensue in the future without any change in existing policy. Baseline projections are used to gauge the extent to which proposed legislation, if enacted into law, would alter current spending and revenue levels.
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• Beneficiary: has the meaning given such term under §. See Tennessee Code 56-7-2802
• Beneficiary: means an individual or other entity entitled to benefits under a policy or annuity. See Tennessee Code 56-7-3403
• Board: means the board of directors of the pool. See Tennessee Code 56-7-2203
• Board: means the Access Tennessee board of directors established pursuant to §. See Tennessee Code 56-7-2902
• Bona fide association: means an association that satisfies the requirements of §. See Tennessee Code 56-7-2802
• carrier: means a health insurance entity as defined in §. See Tennessee Code 56-7-602
• Carrier: means any person that provides one (1) or more health benefit plans in this state, including a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization (HMO) and a multiple employer welfare arrangement (MEWA). See Tennessee Code 56-7-2203
• Case characteristics: means demographic or other objective characteristics of a small employer, as determined by a small employer carrier, that are considered by the small employer carrier in the determination of premium rates for the small employer, but does not mean claim experience, health status and duration of coverage since issue. See Tennessee Code 56-7-2203
• Certificate: means , any certificate delivered or issued for delivery in this state under a group medicare supplement policy. See Tennessee Code 56-7-1501
• Child: means a biological, adopted, or foster son or daughter. See Tennessee Code 56-7-3603
• Chronic condition: means a condition that has an expected duration of one (1) year or more and requires ongoing medical attention or limits activities of daily living, or both. See Tennessee Code 56-7-3702
• Church plan: has the meaning given the term under §. See Tennessee Code 56-7-2802
• Church plan: has the meaning given the term under ERISA, in 29 U. See Tennessee Code 56-7-2902
• Class of business: means all or a distinct grouping of small employers as shown on the records of a small employer carrier. See Tennessee Code 56-7-2203
• COBRA continuation coverage: refers to continuation of coverage offered pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (42 U. See Tennessee Code 56-7-2902
• COBRA continuation provision: means any of the following:
  (A) Section 4980B of the Internal Revenue Code of 1986 (26 U. See Tennessee Code 56-7-2802
• Code: includes the Tennessee Code and all amendments and revisions to the code and all additions and supplements to the code. See Tennessee Code 1-3-105
• Commercial risk insurance: means insurance within the scope of this part that is not "personal risk insurance" as defined in §. See Tennessee Code 56-7-1802
• Commissioner: means the commissioner of mental health and substance abuse services. See Tennessee Code 33-1-101
• Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-7-602
• Commissioner: means the commissioner of finance and administration. See Tennessee Code 56-7-2902
• Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-1-102
• Commissioner: means the commissioner of mental health and substance abuse services, the commissioner's authorized representative, or in the event of the commissioner's absence or a vacancy in the office of commissioner, the deputy commissioner of mental health and substance abuse services. See Tennessee Code 33-2-402
• Common law: The legal system that originated in England and is now in use in the United States. It is based on judicial decisions rather than legislative action.
• Community mental health center: includes for profit corporations and private entities qualified as tax exempt organizations under Internal Revenue Code, §. See Tennessee Code 33-1-101
• Community mental health center: includes any parent or corporate affiliate of a community mental health center as defined in §. See Tennessee Code 33-2-703
• Comparable healthcare service: includes , but is not limited to:
  (A) Physical and occupational therapy services. See Tennessee Code 56-7-602
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Consent: means voluntary agreement to what is reasonably well understood regardless of how the agreement is expressed. See Tennessee Code 33-1-101
• Contract: A legal written agreement that becomes binding when signed.
• Conviction: A judgement of guilt against a criminal defendant.
• cooperative: means a private purchasing cooperative composed of small employers formed under this part. See Tennessee Code 56-7-2203
• Cooperative agreement: means an agreement among two (2) or more community mental health centers for the offering, provision, operation, coordination, planning, funding, pricing, contracting, utilization review, or management of mental health and related services under programs funded or administered by departments or agencies of state government, including, but not limited to, the TennCare program, or the sharing, allocation, or referral of service recipients, personnel, instructional programs, support services, ancillary services, and facilities, or other services traditionally offered by community mental health centers for the programs. See Tennessee Code 33-2-703
• 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.
• Cost sharing requirement: means a copayment, coinsurance, deductible, or annual limitation on cost sharing, including, but not limited to, a limitation subject to 42 U. See Tennessee Code 56-7-3201
• Covered entity: means a covered entity as defined in §. See Tennessee Code 56-7-3201
• Covered person: means a person on whose behalf a health insurance entity offering health insurance coverage is obligated to pay benefits or provide services. See Tennessee Code 56-7-110
• Creditable coverage: means , with respect to an individual, coverage of the individual under any of the following:
  (i) A group health plan. See Tennessee Code 56-7-2802
• Creditable coverage: means , with respect to an individual, coverage of the individual that provides the minimum essential coverage required under 26 U. See Tennessee Code 56-7-2902
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Decedent: A deceased person.
• Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
• Department: means the department of mental health and substance abuse services. See Tennessee Code 33-1-101
• Department: means the department of commerce and insurance. See Tennessee Code 56-7-602
• Department: means the department of finance and administration. See Tennessee Code 56-7-2902
• Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
• Department: means the department of mental health and substance abuse services. See Tennessee Code 33-2-402
• Dependent: A person dependent for support upon another.
• Dependent: means the spouse or child of an eligible employee, subject to applicable terms of the health care plan covering the employee. See Tennessee Code 56-7-2203
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• DMF: means the death master file from the United States social security administration or any other database or service that an insurer may determine is substantially as inclusive as the death master file for determining that a person has reportedly died. See Tennessee Code 56-7-3403
• DMF match: means a search of a DMF that results in a match of a person's social security number or name and date of birth. See Tennessee Code 56-7-3403
• Donor: The person who makes a gift.
• Drug abuse: means a condition characterized by the continuous or episodic use of a drug or drugs resulting in social impairment, vocational impairment, psychological dependence or pathological patterns of use. See Tennessee Code 33-1-101
• 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}
• Eligible employee: means an employee who works for a small employer on a full-time basis, with a normal work week of thirty (30) or more hours, including a sole proprietor, a partner or a partnership, or an independent contractor, if included as an employee under a health care plan of a small employer. See Tennessee Code 56-7-2203
• Emergency healthcare services: means emergency services as defined in §. See Tennessee Code 56-7-3702
• Emergency medical service: means the service used in responding to the perceived individual need for immediate medical care in order to prevent loss of life or aggravation of physiological or psychological illness or injury. See Tennessee Code 56-7-602
• Employee: means an individual for whom an employer must complete a Form I-9 pursuant to federal law and regulations, and does not include an independent contractor. See Tennessee Code 56-7-3603
• Employee: has the meaning given the term under §. See Tennessee Code 56-7-2802
• Employer: has the meaning given the term under §. See Tennessee Code 56-7-2802
• Enrollment date: means , with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for the enrollment. See Tennessee Code 56-7-2802
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• ERISA: means the Employee Retirement Income Security Act of 1974 (29 U. See Tennessee Code 56-7-2902
• Escheat: Reversion of real or personal property to the state when 1) a person dies without leaving a will and has no heirs, or 2) when the property (such as a bank account) has been inactive for a certain period of time. ^{Source: OCC}
• 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.
• Excepted benefits: means benefits under one (1) or more, or any combination, of the following:
  (A) Benefits not subject to requirements:

  (i) Coverage only for accident or disability income insurance, or any combination of accident and disability income insurance. See Tennessee Code 56-7-2802
• Facility: means an institution licensed under title 33 or 68. See Tennessee Code 56-7-3702
• Facility: means a treatment resource, rehabilitation center, hospital, community mental health center, counseling center, clinic, group home, halfway house or any other entity that provides a mental health, service or an alcohol and drug abuse prevention and/or treatment facility. See Tennessee Code 33-2-402
• Family leave insurance: means an insurance policy issued to an employer related to a benefit program provided to an employee to pay for a percentage or portion of the employee's income loss due to:
  (A) The birth or adoption of a child by the employee. See Tennessee Code 56-7-3603
• Family member: means :
  (A) A child, spouse, or parent. See Tennessee Code 56-7-3603
• Federal governmental plan: means a governmental plan established or maintained for its employees by the federal government or by any agency or instrumentality of the federal government. See Tennessee Code 56-7-2802
• Federally defined eligible individual: means an individual:
  (A) For whom, as of the date on which the individual seeks coverage under this part, the aggregate of the periods of creditable coverage is eighteen (18) or more months. See Tennessee Code 56-7-2902
• 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.
• Foreclosure: A legal process in which property that is collateral or security for a loan may be sold to help repay the loan when the loan is in default. ^{Source: OCC}
• Foreign: when used without limitation, includes all companies formed by authority of any other state or government. See Tennessee Code 56-1-102
• Fraud: Intentional deception resulting in injury to another.
• Fund: means the Access Tennessee health insurance program fund established by §. See Tennessee Code 56-7-2902
• Generic alternative: means a drug that is designated to be therapeutically equivalent by the United States food and drug administration's Approved Drug Products with Therapeutic Equivalence Evaluations. See Tennessee Code 56-7-3201
• Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
• Governmental plan: has the meaning given the term under ERISA, §. See Tennessee Code 56-7-2802
• Governmental plan: has the meaning under ERISA, in 29 U. See Tennessee Code 56-7-2902
• Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. ^{Source: Federal Reserve}
• Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with the plan. See Tennessee Code 56-7-2802
• Group health plan: means an employee welfare benefit plan, as defined in ERISA, §. See Tennessee Code 56-7-2802
• Group health plan: means an employee welfare benefit plan as defined in ERISA, in 29 U. See Tennessee Code 56-7-2902
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health benefit plan: means :
  (i) Any accident and health insurance policy or certificate. See Tennessee Code 56-7-2203
• Health care provider: means any person or entity performing services regulated pursuant to title 63 or title 68, chapter 11. See Tennessee Code 56-7-110
• Health insurance coverage: means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care, under any policy, certificate, or agreement offered by a health insurance issuer. See Tennessee Code 56-7-2802
• Health insurance coverage: means any hospital and medical expense incurred policy, nonprofit health care service plan contract, health maintenance organization subscriber contract, or any other health care plan or arrangement that pays for or furnishes medical or health care services, whether by insurance or otherwise. See Tennessee Code 56-7-2902
• Health insurance issuer: means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization and a nonprofit hospital and medical service corporation. See Tennessee Code 56-7-2802
• Health maintenance organization: means :
  (A) A federally qualified health maintenance organization, as defined under federal law. See Tennessee Code 56-7-2802
• Health maintenance organization: means an organization as defined in §. See Tennessee Code 56-7-2902
• Health plan: means health insurance coverage as defined in §. See Tennessee Code 56-7-602
• Health status-related factor: means any of the following factors:
  (A) Health status. See Tennessee Code 56-7-2802
• Healthcare entity: means :
  (A) Any healthcare facility licensed under title 33 or 68. See Tennessee Code 56-7-602
• Healthcare service: means a service rendered by a healthcare provider or at a practice that provides testing, monitoring, diagnosis, or treatment of a human disease or condition, or dispenses medical devices, medical appliances, or medical goods for the treatment of a human disease or condition. See Tennessee Code 56-7-3702
• Hospital: means a public or private hospital or facility or part of a hospital or facility equipped to provide inpatient care and treatment for persons with mental illness or serious emotional disturbance. See Tennessee Code 33-1-101
• Hospital: means a licensed public or private institution as defined in §. See Tennessee Code 56-7-2902
• 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}
• Index rate: means , for each class of business as to a rating period for small employers with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate. See Tennessee Code 56-7-2203
• Individual health insurance coverage: means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance. See Tennessee Code 56-7-2802
• Individual market: means the market for health insurance coverage offered to individuals other than in connection with a group health plan. See Tennessee Code 56-7-2802
• Injunction: An order of the court prohibiting (or compelling) the performance of a specific act to prevent irreparable damage or injury.
• Insane: includes all persons of unsound mind. See Tennessee Code 1-3-105
• Insurance arrangement: means , to the extent permitted by ERISA, any plan, program, contract or other arrangement under which one (1) or more employers, unions or other organizations provide to their employees or members, either directly or indirectly through a trust or third party administration, health care services or benefits other than through an insurer, and shall include any plan described in §. See Tennessee Code 56-7-2902
• insurer: means any life or health insurance company, fraternal benefit society, nonprofit health service corporation, nonprofit hospital service corporation, nonprofit medical service corporation, prepaid health plan, dental care plan, vision care plan, pharmaceutical plan, health maintenance organization, and all similar type organizations. See Tennessee Code 56-7-1603
• Insurer: means any entity that provides health insurance coverage in this state. See Tennessee Code 56-7-2902
• Insurer: means any insurance company authorized to transact life insurance business in this state. See Tennessee Code 56-7-3403
• Interchangeable biological product: means a biological product licensed by the federal food and drug administration and determined to meet the safety standards for determining interchangeability pursuant to 42 U. See Tennessee Code 56-7-3501
• Interest rate: The amount paid by a borrower to a lender in exchange for the use of the lender's money for a certain period of time. Interest is paid on loans or on debt instruments, such as notes or bonds, either at regular intervals or as part of a lump sum payment when the issue matures. ^{Source: OCC}
• Intervenor: means any hospital, physician, allied health professional, health care provider or other person furnishing goods or services to, or in competition with, community mental health center, insurer, hospital service corporation, medical service corporation, hospital and medical services corporation, preferred provider organization, health maintenance organization, behavioral health organization, or any employer or association that directly or indirectly provides health care benefits to its employees or members. See Tennessee Code 33-2-703
• Intestate: Dying without leaving a will.
• Issuer: includes insurance companies, fraternal benefit societies, health care service plans, health maintenance organizations, and any other entity delivering or issuing for delivery in this state medicare supplement policies or certificates. See Tennessee Code 56-7-1501
• Joint committee: Committees including membership from both houses of teh legislature. Joint committees are usually established with narrow jurisdictions and normally lack authority to report legislation.
• 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.
• Large employer: means , in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least fifty-one (51) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year. See Tennessee Code 56-7-2802
• Large group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a large employer. See Tennessee Code 56-7-2802
• Late enrollee: means an eligible employee or dependent who requests enrollment in a health benefit plan of a small employer following the initial enrollment period provided under the terms of the health benefit plan. See Tennessee Code 56-7-2203
• Late enrollee: means , with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during:
  (A) The first period in which the individual is eligible to enroll under the plan. See Tennessee Code 56-7-2802
• 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.
• Licensee: means a proprietorship, a partnership, an association, a governmental agency, or corporation, that operates a facility or a service and has obtained a license under this part. See Tennessee Code 33-2-402
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• Markup: The process by which congressional committees and subcommittees debate, amend, and rewrite proposed legislation.
• Maximum allowable cost: means the maximum amount that a pharmacy benefits manager or covered entity will reimburse a pharmacy for the cost of a drug or a medical product or device. See Tennessee Code 56-7-3102
• Maximum allowable cost list: means a list of drugs, medical products or devices, or both medical products and devices, for which a maximum allowable cost has been established by a pharmacy benefits manager or covered entity. See Tennessee Code 56-7-3102
• Medicaid: means the federal- and state-financed, state-run program of medical assistance established pursuant to Title XIX of the Social Security Act (42 U. See Tennessee Code 56-7-2902
• Medical care: means amounts paid for:
  (A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body. See Tennessee Code 56-7-2802
• Medical care: means :
  (A) The diagnosis, care, mitigation, treatment, or prevention of disease. See Tennessee Code 56-7-2902
• Medicare: means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965. See Tennessee Code 56-7-1501
• Medicare: means coverage under Parts A and/or B of Title XVIII of the Social Security Act (42 U. See Tennessee Code 56-7-2902
• Medicare supplement policy: means a group or individual policy of accident and sickness insurance or a subscriber contract of hospital and medical service associations or health maintenance organizations other than a policy issued pursuant to a contract under §. See Tennessee Code 56-7-1501
• Mental illness: means a psychiatric disorder, alcohol dependence, or drug dependence, but does not include intellectual disability or other developmental disabilities as defined in title 52. See Tennessee Code 33-1-101
• Minor: means any person who has not attained eighteen (18) years of age. See Tennessee Code 1-3-105
• Misappropriation of property: means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of belongings or money without consent. See Tennessee Code 33-2-402
• Month: means a calendar month. See Tennessee Code 1-3-105
• Mortgagee: The person to whom property is mortgaged and who has loaned the money.
• Mortgagor: The person who pledges property to a creditor as collateral for a loan and who receives the money.
• Neglect: means failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness, which results in injury or probable risk of serious harm. See Tennessee Code 33-2-402
• Network plan: means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the issuer. See Tennessee Code 56-7-2802
• New business premium rate: means , for each class of business as to a rating period, the lowest premium rate charged, offered or that could have been charged by a small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage. See Tennessee Code 56-7-2203
• Nonfederal governmental plan: means a governmental plan that is not a federal governmental plan. See Tennessee Code 56-7-2802
• Nonpayment of premium: means failure of the named insured to discharge when due any obligations in connection with the payment of premiums on a policy of automobile liability insurance or any installment of the premium, whether the premium is payable directly to the insurer or its agent or indirectly under any premium finance plan or extension of credit. See Tennessee Code 56-7-1301
• Nonpayment of premium: means failure of the named insured to discharge when due any of its obligations in connection with the payment of premiums on a policy of commercial risk insurance or any installment of the premium, whether the premium is payable directly to the insurer or its agents or indirectly under any premium finance plan or extension of credit. See Tennessee Code 56-7-1802
• Nonresidential office-based opiate treatment facility: includes , but is not limited to, stand-alone clinics, treatment resources, individual physical locations occupied as the professional practice of a prescriber or prescribers licensed pursuant to title 63, or other entities prescribing products containing buprenorphine, or products containing any other controlled substance designed to treat opiate addiction by preventing symptoms of withdrawal to twenty-five percent (25%) or more of its patients or to one hundred fifty (150) or more patients. See Tennessee Code 33-2-402
• 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.
• Participant: has the meaning given the term under ERISA, §. See Tennessee Code 56-7-2802
• 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: includes a corporation, firm, company or association. See Tennessee Code 1-3-105
• Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
• Person: means the policy insured, annuity owner, annuitant, or account owner, as applicable under the policy, annuity, or retained asset account subject to this part. See Tennessee Code 56-7-3403
• Personal property: includes money, goods, chattels, things in action, and evidences of debt. See Tennessee Code 1-3-105
• Personal property: All property that is not real property.
• Personal representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
• Personal support services: means nursing consultation, education services, and other personal assistance services as defined by rule, which are provided to individuals with substantial limitation in two (2) or more major life activities in either their regular or temporary residences, but does not mean direct nursing services provided in connection with an acute episode of illness or injury. See Tennessee Code 33-2-402
• Pharmacy benefits manager: includes , but is not limited to, a health insurance issuer, managed health insurance issuer as defined in §. See Tennessee Code 56-7-3102
• Pharmacy benefits manager: means a pharmacy benefits manager as defined in §. See Tennessee Code 56-7-3201
• Pharmacy services administrative organization: means an entity that provides contracting and other administrative services to pharmacies to assist them in their interaction with third-party payers, pharmacy benefits managers, drug wholesalers, and other entities. See Tennessee Code 56-7-3102
• Physician: means a medical doctor or osteopathic physician with a valid state medical license issued pursuant to title 63, chapter 6 or 9. See Tennessee Code 56-7-3702
• Plaintiff: The person who files the complaint in a civil lawsuit.
• Plan of operation: means the articles, bylaws, and operating rules and procedures adopted by the board pursuant to §. See Tennessee Code 56-7-2902
• Plan sponsor: has the meaning given the term under §. See Tennessee Code 56-7-2802
• Pleadings: Written statements of the parties in a civil case of their positions. In the federal courts, the principal pleadings are the complaint and the answer.
• Policy: means any policy or certificate of life insurance issued in this state, but does not include any policy or certificate of life insurance that provides a death benefit under:
  (A) An employee benefit plan subject to the Employee Retirement Income Security Act of 1974, as periodically amended, compiled at 29 U. See Tennessee Code 56-7-3403
• policy form: means :
  (A) Any policy, contract, plan or agreement of life or health insurance, including credit life insurance and credit health insurance, delivered or issued for delivery in this state by any company subject to this part. See Tennessee Code 56-7-1603
• Practice: means an entity formed with at least one (1) healthcare provider to provide healthcare services. See Tennessee Code 56-7-3702
• Preexisting condition exclusion: means , with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. See Tennessee Code 56-7-2802
• Preexisting conditions provision: means a policy provision that limits or excludes coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage, for a condition that, during a specified period immediately preceding the effective date of coverage, had manifested itself in a manner that would cause an ordinarily prudent person to seek diagnosis, care or treatment, or for which medical advice, diagnosis, care or treatment was recommended or received as to that condition or as to pregnancy existing on the effective date of coverage. See Tennessee Code 56-7-2203
• Premium: includes insurance premiums or other fees charged for a health benefit plan, including the costs of benefits paid or reimbursements made to or on behalf of persons covered by the plan. See Tennessee Code 56-7-2203
• Prescription drug: means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs. See Tennessee Code 56-7-3201
• Prescription drug: means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs. See Tennessee Code 56-7-3501
• Prior authorization: means a written or oral determination made by a health carrier or utilization review organization, or an agent of such carrier or organization, that an enrollee's receipt of a healthcare service is a covered benefit under the applicable plan and that a requirement of medical necessity or other requirements imposed by such utilization review organization as prerequisites for payment for such services have been satisfied. See Tennessee Code 56-7-3702
• Private passenger automobile liability insurance policy: means a policy delivered or issued for delivery in this state, insuring a natural person as named insured, or one (1) or more related individuals resident of the same household, and under which the insured vehicles therein designated are of the following types only:
  (A) A motor vehicle of the private passenger or station wagon type that is not used as a public or livery conveyance for passengers, nor rented to others. See Tennessee Code 56-7-1301
• Probable cause: A reasonable ground for belief that the offender violated a specific law.
• Program: means the Access Tennessee health insurance program, created in §. See Tennessee Code 56-7-2902
• Property: includes both personal and real property. See Tennessee Code 1-3-105
• provider: means any person or entity performing services regulated pursuant to title 63 or title 68, chapter 11, with whom the health insurance entity has an express and valid network provider agreement or contract. See Tennessee Code 56-7-3301
• Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
• Rating period: means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier. See Tennessee Code 56-7-2203
• Reasonably accurate: means information determined through application by the health insurance entity of contract rates, fee schedules and reimbursement rules and policies in effect as of the date inquiry is made by the provider. See Tennessee Code 56-7-3301
• Record: means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in a perceivable form. See Tennessee Code 1-3-105
• Record keeping services: means those circumstances under which the insurer has agreed with a group life insurance policyholder to be responsible for obtaining, maintaining, and administering in its own systems information about each individual insured under the policyholder's group life insurance contract at least the following information:
  (A) Individual insured's social security number or name and date of birth. See Tennessee Code 56-7-3403
• Recoupment: means the action by a health insurance entity to recover amounts previously paid to a health care provider by withholding or setting off the amounts against current payments to the health care provider. See Tennessee Code 56-7-110
• 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.
• Reporter: Makes a record of court proceedings and prepares a transcript, and also publishes the court's opinions or decisions (in the courts of appeals).
• Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
• Reputable and responsible character: means that the applicant or licensee can be trusted with responsibility for persons who are particularly vulnerable to abuse, neglect, and financial or sexual exploitation. See Tennessee Code 33-2-402
• Required prescription drug: means a medication that is required as part of a step therapy protocol. See Tennessee Code 56-7-3501
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Resident: means an individual who is legally domiciled in Tennessee. See Tennessee Code 56-7-2902
• Revocable trust: A trust agreement that can be canceled, rescinded, revoked, or repealed by the grantor (person who establishes the trust).
• Serious emotional disturbance: means a condition in a child who currently or at any time during the past year has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet psychiatric diagnostic criteria that results in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities and includes any mental disorder, regardless of whether it is of biological etiology. See Tennessee Code 33-1-101
• Serious health condition: means an illness, injury, impairment, or physical or mental condition, including transplantation preparation and recovery from surgery related to organ or tissue donation, that involves inpatient care in a hospital, hospice, or residential healthcare facility, continuing treatment or continuing supervision by a healthcare provider as defined in an insurance policy issued under this part. See Tennessee Code 56-7-3603
• Service: includes any activity to prevent, treat, or ameliorate mental illness, serious emotional disturbance or alcohol or drug use which includes diagnosis, evaluation, residential assistance, training, habilitation, rehabilitation, prevention, treatment, counseling, case coordination, or supervision of persons with mental illness, alcohol and drug abuse issues and serious emotional disturbances. See Tennessee Code 33-2-402
• Service member: means a member of the United States armed forces in active military service. See Tennessee Code 56-7-3603
• Service of process: The service of writs or summonses to the appropriate party.
• Service recipient: means a person who is receiving service, has applied for service, or for whom someone has applied for or proposed service because the person has mental illness or serious emotional disturbance. See Tennessee Code 33-1-101
• 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.
• Shopping and decision support program: means the program established by a carrier pursuant to this part. See Tennessee Code 56-7-602
• signed: includes a mark, the name being written near the mark and witnessed, or any other symbol or methodology executed or adopted by a party with intention to authenticate a writing or record, regardless of being witnessed. See Tennessee Code 1-3-105
• Significant break in coverage: means a period of sixty-three (63) consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage. See Tennessee Code 56-7-2902
• small employer: includes any person that, during the preceding year, employed no less than two (2) and no more than fifty (50) eligible employees and otherwise qualifies as a small employer pursuant to this subdivision (18). See Tennessee Code 56-7-2203
• Small employer: means , in connection with a group health plan with respect to a calendar year and a plan year, an employer who employs an average of at least two (2) but no more than fifty (50) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year. See Tennessee Code 56-7-2802
• Small employer carrier: means any carrier that offers health benefit plans covering eligible employees of one (1) or more small employers. See Tennessee Code 56-7-2203
• Small group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a small employer. See Tennessee Code 56-7-2802
• State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
• Statute: A law passed by a legislature.
• Statute of limitations: A law that sets the time within which parties must take action to enforce their rights.
• Step therapy protocol: means a protocol, policy, or program that establishes a specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are covered by a health carrier or health benefit plan. See Tennessee Code 56-7-3501
• Subscriber: means a person obligated under a reciprocal insurance agreement. See Tennessee Code 56-16-102
• Subscription: includes a mark, the name being written near the mark and witnessed. See Tennessee Code 1-3-105
• Support: means any activity or resource that enables a service recipient to participate in a service for mental illness or serious emotional disturbance or in community life. See Tennessee Code 33-1-101
• Testate: To die leaving a will.
• Third party administrator: means any entity that, on behalf of an insurer or insurance arrangement, provides health insurance coverage to individuals in this state, receives or collects charges, contributions or premiums for, or adjudicates, processes or settles claims in connection with, any type of health benefit provided in or as an alternative to health insurance coverage. See Tennessee Code 56-7-2902
• Tort: A civil wrong or breach of a duty to another person, as outlined by law. A very common tort is negligent operation of a motor vehicle that results in property damage and personal injury in an automobile accident.
• Treatment resource: means any public or private facility, service, or program providing treatment or rehabilitation services for mental illness or serious emotional disturbance, including, but not limited to, detoxification centers, hospitals, community mental health centers, clinics or programs, halfway houses, and rehabilitation centers. See Tennessee Code 33-1-101
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• Trustee: A person or institution holding and administering property in trust.
• Uniform Commercial Code: A set of statutes enacted by the various states to provide consistency among the states' commercial laws. It includes negotiable instruments, sales, stock transfers, trust and warehouse receipts, and bills of lading. ^{Source: OCC}
• United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Utilization review organization: means :
  (A) A health carrier or other entity, including a designee of such carrier or entity, that reviews or issues prior authorizations for a health carrier. See Tennessee Code 56-7-3702
• Utilization review organization: means an entity that conducts utilization review, as defined in §. See Tennessee Code 56-7-3501
• Verdict: The decision of a petit jury or a judge.
• Waiting period: means , with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. See Tennessee Code 56-7-2802
• Writ of certiorari: An order issued by the Supreme Court directing the lower court to transmit records for a case for which it will hear on appeal.
• written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
• Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105