Definitions

For the purpose of this Chapter, the following words and phrases have the meanings assigned to them, respectively, except where the context otherwise requires:

(a)“Claim” means any claim, bill, or request for payment for all or any portion of healthcare services provided by a healthcare provider, or services submitted by a patient or Health Care Provider that is eligible for reimbursement.

(b)“Clean Claim” means a claim, or portion thereof, that may be processed without a reasonable request for additional information from the provider of service or from a third party, but does not include any claim under investigation for fraud or abuse or claims under review for medical necessity. In no event may a claim be contested or denied for the lack of information that has no factual impact upon the Health Plan Administrator’s ability to adjudicate the claim.

(c)“Contest”, “contesting” or “contested” means the circumstances under which a payer entity was not provided with, or did not have reasonable access to, sufficient pertinent information needed to determine payment liability or basis for payment of the claims.

(d)“Deny”, “denying” or “denied” means the assertion by a Health Plan Administrator that it has no, or partial, liability to pay a claim based upon eligibility of the patient, coverage of a service, medical necessity of a service, liability of another payer or other grounds. CH. 9 CONSUMER HEALTH PROTECTION ACT

(e)“Health Plan Administrator” means insurance companies, health plan providers, all companies defined as third party payers, including, but not limited to, health maintenance organizations, medical service organizations, governmental organizations, worker’s compensation organization, or other legal entities providing or applying to provide third party payment or health insurance or payment for healthcare services that are organized and operating under the laws of Guam.

(f)“Health Care Provider” means any health care facility, hospital, clinic, laboratory, nursing home, home health agency, pharmacy, physician, dentist, nurse, acupuncturist, chiropractor, or any other practitioner or organized entity certified or licensed to provide health care services on Guam.