69O-153.001. Definitions

For purposes of this chapter:

(1) The term “False Claim” means any written statement which is a part of or supports a claim for payment or other benefit pursuant to an insurance policy or health maintenance organization coverage document for commercial or personal insurance or health maintenance organization coverage and which is knowingly presented or prepared with knowledge or belief that it will be presented to an insurer, health maintenance organization, or third party, and which the preparer or presenter knows to contain materially false information or omissions, as part of or in support of or concerning that claim.

(2) The term “claimant” includes but is not limited to a patient, a health care provider to whom, or a health care facility to which the patient has either assigned his claim for payment or is otherwise entitled to care under a health maintenance organization coverage document.

(3) The term “Health Care Provider” means a physician or any recognized practitioner who provided skilled services pursuant to the prescription of or under the supervision or direction of a physician.

(4) The term “Health Care Facility” means any hospital licensed under Chapter 395, F.S., and any health care institution licensed under Chapter 400, F.S.

(5) The term “Pre-provision of services agreement” means an agreement made or understood to exist in advance of the provision of health care services between the health care provider or health care facility and the patient to waive in whole or in part that patient’s payment of the co-payment or deductible amount provided for in the contractual agreement otherwise known as the “policy”, or “health maintenance organization coverage document” between the patient and the insurer, health maintenance organization or third party, or an agreement to give the patient a discount for the immediate payment of fees for services rendered.

(6) The term “Third Party” means any individual who, or entity which, collects premiums, assumes financial risks, pays claims, or provides administrative services relative to any insurance policy, insurance contract, health prepayment contract, health car plan, nonprofit health care plan, nonprofit health service plan contract, or employee welfare plan.

(7) The term “insurer, health maintenance organization, or third party” as used in this rule does not include any federally-funded programs, such as Medicare and CHAMPUS or any state-funded programs for the medically indigent or disabled, such as Medicaid, or the agents, contractors, or administrators of these federally-funded or state-funded programs.

Specific Authority 626.9611, 641.36 FS. Law Implemented 624.307(1), 626.9541(1)(u), 641.3903(11) FS. History–New 2-28-90, Formerly 4-86.001, 4-153.001.