                                 CODE OF VIRGINIA

DEFINITIONS (§ 32.1-276.3)

As used in this chapter:
		&#8220;Actual reimbursement amount&#8221; means reimbursement information
included in the claims data submitted by data suppliers to the Virginia
All-Payer Claims Database, whether such information is referred to in the claims
data as &#8220;paid amounts,&#8221; &#8220;allowed amounts,&#8221; or another
term having the same or similar meaning and whether in reference to the payer
who paid the actual reimbursement amount or the provider who received the actual
reimbursement amount.
		&#8220;Board&#8221; means the Board of Health.
		&#8220;Common data layout&#8221; means the national data collection standard
adopted and maintained by the APCD Council.
		&#8220;Consumer&#8221; means any person (i) whose occupation is other than the
administration of health activities or the provision of health services, (ii)
who has no fiduciary obligation to a health care institution or other health
agency or to any organization, public or private, whose principal activity is an
adjunct to the provision of health services, or (iii) who has no material
financial interest in the rendering of health services.
		&#8220;Covered lives&#8221; means subscribers, policyholders, members,
enrollees, or dependents, as the case may be, under a policy or contract issued
or issued for delivery in Virginia by a managed care health insurance plan
licensee, insurer, health services plan, or preferred provider organization.
		&#8220;ERISA plan&#8221; means any self-funded employee welfare benefit plan
governed by the requirements of the Employee Retirement Income Security Act of
1974, 29 U.S.C. § 1002(1).
		&#8220;Health care provider&#8221; means (i) a general hospital, ordinary
hospital, outpatient surgical hospital, nursing home or certified nursing
facility licensed or certified pursuant to Article 1 (§ 32.1-123 et seq.) of
Chapter 5 of this title; (ii) a mental or psychiatric hospital licensed pursuant
to Article 2 (§ 37.2-403 et seq.) of Chapter 4 of Title 37.2; (iii) a hospital
operated by the Department of Behavioral Health and Developmental Services; (iv)
a hospital operated by the University of Virginia or the Virginia Commonwealth
University Health System Authority; (v) any person licensed to practice medicine
or osteopathy in the Commonwealth pursuant to Chapter 29 (§ 54.1-2900 et seq.)
of Title 54.1; (vi) any person licensed to furnish health care policies or plans
pursuant to Chapter 34 (§ 38.2-3400 et seq.), Chapter 42 (§ 38.2-4200), or
Chapter 43 (§ 38.2-4300) of Title 38.2; or (vii) any person licensed to
practice dentistry pursuant to Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1
who is registered with the Board of Dentistry as an oral and maxillofacial
surgeon and certified by the Board of Dentistry to perform certain procedures
pursuant to § 54.1-2709.1. In no event shall such term be construed to include
continuing care retirement communities which file annual financial reports with
the State Corporation Commission pursuant to Chapter 49 (§ 38.2-4900 et seq.)
of Title 38.2 or any nursing care facility of a religious body which depends
upon prayer alone for healing.
		&#8220;Health maintenance organization&#8221; means any person who undertakes
to provide or to arrange for one or more health care plans pursuant to Chapter
43 (§ 38.2-4300 et seq.) of Title 38.2.
		&#8220;Inpatient hospital&#8221; means a hospital providing inpatient care and
licensed pursuant to Article 1 (§ 32.1-123 et seq.) of Chapter 5, a hospital
licensed pursuant to Article 2 (§ 37.2-403 et seq.) of Chapter 4 of Title 37.2,
a hospital operated by the Department of Behavioral Health and Developmental
Services for the care and treatment of individuals with mental illness, or a
hospital operated by the University of Virginia or the Virginia Commonwealth
University Health System Authority.
		&#8220;Nonprofit organization&#8221; means a nonprofit, tax-exempt health data
organization with the characteristics, expertise, and capacity to execute the
powers and duties set forth for such entity in this chapter.
		&#8220;Oral and maxillofacial surgeon&#8221; means, for the purposes of this
chapter, a person who is licensed to practice dentistry in Virginia, registered
with the Board of Dentistry as an oral and maxillofacial surgeon, and certified
to perform certain procedures pursuant to § 54.1-2709.1.
		&#8220;Oral and maxillofacial surgeon&#8217;s office&#8221; means a place (i)
owned or operated by a licensed and registered oral and maxillofacial surgeon
who is certified to perform certain procedures pursuant to § 54.1-2709.1 or by
a group of oral and maxillofacial surgeons, at least one of whom is so
certified, practicing in any legal form whatsoever or by a corporation,
partnership, limited liability company or other entity that employs or engages
at least one oral and maxillofacial surgeon who is so certified, and (ii)
designed and equipped for the provision of oral and maxillofacial surgery
services to ambulatory patients.
		&#8220;Outpatient surgery&#8221; means all surgical procedures performed on an
outpatient basis in a general hospital, ordinary hospital, outpatient surgical
hospital or other facility licensed or certified pursuant to Article 1 (§
32.1-123 et seq.) of Chapter 5 of this title or in a physician&#8217;s office or
oral and maxillofacial surgeon&#8217;s office, as defined above. Outpatient
surgery refers only to those surgical procedure groups on which data are
collected by the nonprofit organization as a part of a pilot study.
		&#8220;Physician&#8221; means a person licensed to practice medicine or
osteopathy in the Commonwealth pursuant to Chapter 29 (§ 54.1-2900 et seq.) of
Title 54.1.
		&#8220;Physician&#8217;s office&#8221; means a place (i) owned or operated by
a licensed physician or group of physicians practicing in any legal form
whatsoever or by a corporation, partnership, limited liability company or other
entity that employs or engages physicians and (ii) designed and equipped solely
for the provision of fundamental medical care, whether diagnostic, therapeutic,
rehabilitative, preventive or palliative, to ambulatory patients.
		&#8220;Surgical procedure group&#8221; means at least five procedure groups,
identified by the nonprofit organization designated pursuant to § 32.1-276.4 in
compliance with regulations adopted by the Board, based on criteria that
include, but are not limited to, the frequency with which the procedure is
performed, the clinical severity or intensity, and the perception or probability
of risk. The nonprofit organization shall form a technical advisory group
consisting of members nominated by its Board of Directors&#8217; nominating
organizations to assist in selecting surgical procedure groups to recommend to
the Board for adoption.
		&#8220;System&#8221; means the Virginia Patient Level Data System.

HISTORY: 1996, cc. 902, 905, 1046; 1999, c. 764; 2000, cc. 720, 897; 2001, c.
341; 2003, c. 466; 2009, cc. 813, 840; 2019, cc. 672, 673.