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General Laws

Section 1. The following words as used in this chapter shall have the meanings given to them in this section unless the context clearly requires otherwise:

“Commissioner”, the commissioner of insurance.

“Covered person”, any policy holder or other person on whose behalf the organization is obligated to pay for or provide health care services.

“Covered services”, health care services which the organization is obligated to pay for or provide under the health benefit plan.

“Emergency care”, services provided in or by a hospital emergency facility to a covered person after the development of a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the covered person’s or another person’s health in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).

“Health benefit plan”, the health insurance policy, subscriber agreement, or contract between the covered person and an organization which defines the covered services and benefit levels available.

“Health care provider”, a provider of health care services licensed or registered pursuant to chapter one hundred and eleven or chapter one hundred and twelve.

“Health care services”, services rendered or products sold by a health care provider within the scope of the provider’s license. The term includes, but is not limited to, hospital, medical, surgical, dental, vision, and pharmaceutical services or products.

“Organization”, an insurer authorized to write accident and health insurance under chapter one hundred and seventy-five, a nonprofit hospital service corporation authorized under chapter one hundred and seventy-six A, a nonprofit medical service corporation authorized under chapter one hundred and seventy-six B, a dental service corporation authorized under chapter one hundred and seventy-six E, an optometric service corporation authorized under chapter one hundred and seventy-six F, a health maintenance organization authorized under chapter one hundred and seventy-six G, an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, or any other entity approved by the commissioner under this chapter.

“Preferred provider”, a health care provider or group of health care providers who have contracted to provide specified covered services.

“Preferred provider arrangement”, a contract between or on behalf of an organization and a preferred provider which complies with all the requirements of this chapter.

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