(1) As used in this subchapter:(1) “Covered materials” means materials for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;(2) “Covered services” means services for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;(3) “Enrollee” means an individual participating in a health benefit plan, vision benefit plan, or vision benefit discount plan that is purchased by an individual or provided to an individual by an insurer, company, organization, group, employer, government assistance program, or another entity that purchases or supplies coverage for a health benefit plan, vision care benefit plan, or vision benefit discount plan;(4) “Extrapolation” means a mathematical formula, process, or technique used by a vision benefit manager or the vision benefit manager's agent, in an audit of an optometrist to estimate audit results or findings for a larger batch or group of claims not reviewed by the vision benefit manager;(5) “Insurer” means an insurance company, a health maintenance organization, a hospital and medical service corporation, or a self-insured health plan for employees of a governmental entity;(6) “Materials” means ophthalmic devices, including without limitation:(A) Lenses;(B) Devices containing lenses;(C) Contact lenses;(D) Artificial intraocular lenses;(E) Ophthalmic frames;(F) Lens-mounting apparatus;(G) Prisms;(H) Spectacle or contact lens treatments and coatings;(I) Prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;(J) Low-vision devices; and(K) Vision therapy devices;(7) “Noncovered materials” means materials that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;(8) “Noncovered services” means services that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;(9) “Participating provider agreement” means an agreement between a vision care provider and an insurer that obligates a vision care provider to provide for compensation services and materials to an individual who is insured by the insurer;(10) “Services” means benefits or services provided by a vision care provider;(11) “Vision benefit manager” means an individual, company, organization, group, or other entity, including without limitation an insurer, third party administrator, and a subcontractor, that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan, vision benefit discount plan, or other insurance policy or contract that provides vision benefits or discounts to an enrollee pertaining to the provision of covered services or covered materials;(12) “Vision benefit plan or contract” means a plan, contract, or policy of insurance issued by an insurer that provides for vision care benefits, materials, or services;(13) “Vision care discount plan” means a separate plan to provide benefits or services under a rider to a health benefit plan or as a stand-alone agreement that is authorized by a vision care provider to provide discounts to individuals under the Primary Eye Care Provider Act, § 23-99-301 et seq.;(14) “Vision care plan” means an entity that provides health benefits and that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan or contract; and(15) “Vision care provider” means an individual licensed as an optometrist under § 17-90-301 et seq., or a licensed osteopathic or medical physician licensed under § 17-91-101 et seq. or § 17-95-401 et seq., if the physician has also completed a residency in ophthalmology.
(1) “Covered materials” means materials for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(2) “Covered services” means services for which reimbursement from the insurer, vision benefit manager, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(3) “Enrollee” means an individual participating in a health benefit plan, vision benefit plan, or vision benefit discount plan that is purchased by an individual or provided to an individual by an insurer, company, organization, group, employer, government assistance program, or another entity that purchases or supplies coverage for a health benefit plan, vision care benefit plan, or vision benefit discount plan;
(4) “Extrapolation” means a mathematical formula, process, or technique used by a vision benefit manager or the vision benefit manager's agent, in an audit of an optometrist to estimate audit results or findings for a larger batch or group of claims not reviewed by the vision benefit manager;
(5) “Insurer” means an insurance company, a health maintenance organization, a hospital and medical service corporation, or a self-insured health plan for employees of a governmental entity;
(6) “Materials” means ophthalmic devices, including without limitation:(A) Lenses;(B) Devices containing lenses;(C) Contact lenses;(D) Artificial intraocular lenses;(E) Ophthalmic frames;(F) Lens-mounting apparatus;(G) Prisms;(H) Spectacle or contact lens treatments and coatings;(I) Prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;(J) Low-vision devices; and(K) Vision therapy devices;
(A) Lenses;
(B) Devices containing lenses;
(C) Contact lenses;
(D) Artificial intraocular lenses;
(E) Ophthalmic frames;
(F) Lens-mounting apparatus;
(G) Prisms;
(H) Spectacle or contact lens treatments and coatings;
(I) Prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;
(J) Low-vision devices; and
(K) Vision therapy devices;
(7) “Noncovered materials” means materials that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;
(8) “Noncovered services” means services that are not covered by an insurer, a vision benefit manager, a vision care plan, or a vision care discount plan;
(9) “Participating provider agreement” means an agreement between a vision care provider and an insurer that obligates a vision care provider to provide for compensation services and materials to an individual who is insured by the insurer;
(10) “Services” means benefits or services provided by a vision care provider;
(11) “Vision benefit manager” means an individual, company, organization, group, or other entity, including without limitation an insurer, third party administrator, and a subcontractor, that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan, vision benefit discount plan, or other insurance policy or contract that provides vision benefits or discounts to an enrollee pertaining to the provision of covered services or covered materials;
(12) “Vision benefit plan or contract” means a plan, contract, or policy of insurance issued by an insurer that provides for vision care benefits, materials, or services;
(13) “Vision care discount plan” means a separate plan to provide benefits or services under a rider to a health benefit plan or as a stand-alone agreement that is authorized by a vision care provider to provide discounts to individuals under the Primary Eye Care Provider Act, § 23-99-301 et seq.;
(14) “Vision care plan” means an entity that provides health benefits and that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan or contract; and
(15) “Vision care provider” means an individual licensed as an optometrist under § 17-90-301 et seq., or a licensed osteopathic or medical physician licensed under § 17-91-101 et seq. or § 17-95-401 et seq., if the physician has also completed a residency in ophthalmology.