20-3101. Definitions

In this article, unless the context otherwise requires:

1. "Adjudicate" means an insurer's decision to deny or pay a claim, in whole or in part, including the decision as to how much to pay.

2. "Clean claim" means a written or electronic claim for health care services or benefits that may be processed without obtaining additional information, including coordination of benefits information, from the health care provider, the enrollee or a third party, except in cases of fraud.

3. "Enrollee" means an individual who is enrolled under a health care insurer's policy, contract or evidence of coverage.

4. "Grievance":

(a) Means any written complaint that is subject to resolution through the insurer's system that is prescribed in section 20-3102, subsection F and submitted by a health care provider and received by a health care insurer. 

(b) Includes any delay in the timeliness of claim adjudication that results in a delay of payment of a clean claim as prescribed in section 20-3102.

(c) Does not include a complaint:

(i) By a noncontracted provider regarding an insurer's decision to deny the noncontracted provider admission to the insurer's network.

(ii) About an insurer's decision to terminate a health care provider from the insurer's network.

(iii) That is the subject of a health care appeal pursuant to chapter 15, article 2 of this title. 

5. "Health care insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, prepaid dental plan organization, hospital service corporation, medical service corporation, dental service corporation, optometric service corporation, or hospital, medical, dental and optometric service corporation.