Article I, Section A – Definitions. Add “Conditional Provider Network Approval” as a new definition after the definition of “Comprehensive Care Plan (for Medicaid SSI members only)”: Conditional Provider Network Approval: Refers to the HMO provider network approval status for a county when network adequacy deficiencies are identified in current certification counties.
Article I, Section A – Definitions. Add “Copayment” as a new definition after the definition of “Coordination of Benefits (COB)”: Copayment: A fixed amount the HMO or provider is allowed to charge a member for part of the cost of medically necessary covered services. Allowable copayment amounts are listed in the ForwardHealth online handbook.
Article I, Section A – Definitions. Move the definition of “Medically Necessary” after the definition of “Medical Status Code”
Article I, Section A – Definitions. Add “Program Integrity” as a new definition after the definition of “Primary Care Provider (PCP)”: Program Integrity: As defined by CMS, it is the commitment to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid enrollees. This includes, but is not limited to, the responsibility to review Medicaid provider activities, audit claims, identify and recover overpayments, and provider and public education.
Article I, Section A – Definitions. Add “Rate Region” as a new definition after the definition of “Rate Cell”: Rate Region: A grouping of counties with similar rate-setting attributes such as geography, member cost, and provider networks.
