State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_90 > GS_90-21_50

Article 1G.

Health Care Liability.

§ 90‑21.50. Definitions.

As used in this Article,unless the context clearly indicates otherwise, the term:

(1)        "Health benefitplan" means an accident and health insurance policy or certificate; anonprofit hospital or medical service corporation contract; a healthmaintenance organization subscriber contract; a self‑insured indemnityprogram or prepaid hospital and medical benefits plan offered under the StateHealth Plan for Teachers and State Employees and subject to the requirements ofArticle 3 of Chapter 135 of the General Statutes, a plan provided by a multipleemployer welfare arrangement; or a plan provided by another benefitarrangement, to the extent permitted by the Employee Retirement Income SecurityAct of 1974, as amended, or by any waiver of or other exception to that actprovided under federal law or regulation. Except for the Health InsuranceProgram for Children established under Part 8 of Article 2 of Chapter 108A ofthe General Statutes, "Health benefit plan" does not mean any planimplemented or administered by the North Carolina or United States Departmentof Health and Human Services, or any successor agency, or its representatives."Health benefit plan" does not mean any of the following kinds of insurance:

a.         Accident.

b.         Credit.

c.         Disability income.

d.         Long‑term ornursing home care.

e.         Medicare supplement.

f.          Specified disease.

g.         Dental or vision.

h.         Coverage issued as asupplement to liability insurance.

i.          Workers'compensation.

j.          Medical paymentsunder automobile or homeowners.

k.         Hospital income orindemnity.

l.          Insurance underwhich benefits are payable with or without regard to fault and that isstatutorily required to be contained in any liability policy or equivalent self‑insurance.

m.        Short‑termlimited duration health insurance policies as defined in Part 144 of Title 45of the Code of Federal Regulations.

(2)        "Health caredecision" means a determination that is made by a managed care entity andis subject to external review under Part 4 of Article 50 of Chapter 58 of theGeneral Statutes and is also a determination that:

a.         Is anoncertification, as defined in G.S. 58‑50‑61, of a prospective orconcurrent request for health care services, and

b.         Affects the qualityof the diagnosis, care, or treatment provided to an enrollee or insured of thehealth benefit plan.

(3)        "Health careprovider" means:

a.         An individual who islicensed, certified, or otherwise authorized under this Chapter to providehealth care services in the ordinary course of business or practice of aprofession or in an approved education or training program; or

b.         A health carefacility, licensed under Chapters 131E or 122C of the General Statutes, wherehealth care services are provided to patients;

"Healthcare provider" includes: (i) an agent or employee of a health carefacility that is licensed, certified, or otherwise authorized to provide healthcare services; (ii) the officers and directors of a health care facility; and(iii) an agent or employee of a health care provider who is licensed,certified, or otherwise authorized to provide health care services.

(4)        "Health careservice" means a health or medical procedure or service rendered by ahealth care provider that:

a.         Provides testing,diagnosis, or treatment of a health condition, illness, injury, or disease; or

b.         Dispenses drugs,medical devices, medical appliances, or medical goods for the treatment of ahealth condition, illness, injury, or disease.

(5)        "Insured orenrollee" means a person that is insured by or enrolled in a healthbenefit plan under a policy, plan, certificate, or contract issued or deliveredin this State by an insurer.

(6)        "Insurer"means an entity that writes a health benefit plan and that is an insurancecompany subject to Chapter 58 of the General Statutes, a service corporationorganized under Article 65 of Chapter 58 of the General Statutes, a healthmaintenance organization organized under Article 67 of Chapter 58 of theGeneral Statutes, a self‑insured health maintenance organization ormanaged care entity operated or administered by or under contract with theExecutive Administrator and Board of Trustees of the State Health Plan forTeachers and State Employees pursuant to Article 3 of Chapter 135 of theGeneral Statutes, a multiple employer welfare arrangement subject to Article 49of Chapter 58 of the General Statutes, or the State Health Plan for Teachersand State Employees.

(7)        "Managed careentity" means an insurer that:

a.         Delivers,administers, or undertakes to provide for, arrange for, or reimburse for healthcare services or assumes the risk for the delivery of health care services; and

b.         Has a system ortechnique to control or influence the quality, accessibility, utilization, orcosts and prices of health care services delivered or to be delivered to adefined enrollee population.

Exceptfor the State Health Plan for Teachers and State Employees and the HealthInsurance Program for Children, "managed care entity" does notinclude: (i) an employer purchasing coverage or acting on behalf of itsemployees or the employees of one or more subsidiaries or affiliatedcorporations of the employer, or (ii) a health care provider.

(8)        "Ordinarycare" means that degree of care that, under the same or similarcircumstances, a managed care entity of ordinary prudence would have used atthe time the managed care entity made the health care decision.

(9)        "Physician"means:

a.         An individuallicensed to practice medicine in this State;

b.         A professionalassociation or corporation organized under Chapter 55B of the General Statutes;or

c.         A person or entitywholly owned by physicians.

(10)      "Successorexternal review process" means an external review process equivalent inall respects to G.S. 58‑50‑75 through G.S. 58‑50‑95that is approved by the Department and implemented by a health benefit plan inthe event that G.S. 58‑50‑75 through G.S. 58‑50‑95 arefound by a court of competent jurisdiction to be void, unenforceable, orpreempted by federal law, in whole or in part. (2001‑446, s. 4.7; 2007‑323, s. 28.22A(o);2007‑345, s. 12.)