Montana Code Annotated 2021



Part 17. Preferred Provider Agreements


33-22-1703. Definitions. As used in this part, the following definitions apply:

(1) "Emergency medical condition" means a condition manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(a) the covered person's health would be in serious jeopardy;

(b) the covered person's bodily functions would be seriously impaired; or

(c) a bodily organ or part would be seriously damaged.

(2) "Emergency services" means health care items or services furnished or required to evaluate and treat an emergency medical condition.

(3) "Health benefit plan" means the health insurance policy or subscriber arrangement between the insured or subscriber and the health care insurer that defines the covered services and benefit levels available.

(4) "Health care insurer" means:

(a) an insurer that provides disability insurance as defined in 33-1-207;

(b) a health service corporation as defined in 33-30-101;

(c) a fraternal benefit society as described in 33-7-105; or

(d) any other entity regulated by the commissioner that provides health coverage except a health maintenance organization.

(5) "Health care services" means health care services or products rendered or sold by a provider within the scope of the provider's license or legal authorization or services provided under Title 33, chapter 22, part 7.

(6) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy or subscriber contract issued or administered by an insurer.

(7) "Preferred provider" means a provider or group of providers who have contracted to provide specified health care services.

(8) "Preferred provider agreement" means a contract between or on behalf of a health care insurer and a preferred provider.

(9) "Provider" means an individual or entity licensed or legally authorized to provide health care services or services covered within Title 33, chapter 22, part 7.

(10) "Subscriber" means a certificate holder or other person on whose behalf the health care insurer is providing or paying for health care coverage.

History: En. Sec. 3, Ch. 638, L. 1987; amd. Sec. 67, Ch. 713, L. 1989; amd. Sec. 40, Ch. 586, L. 1991; amd. Sec. 32, Ch. 451, L. 1993; amd. Sec. 1, Ch. 413, L. 1997.