Common use of Disability Competency Clause in Contracts

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary who is enrolled in Medicare. Dual Eligible Special Needs Plan (D-SNP) — A Medicare Advantage Plan that Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, indicated by the eligibility start and end dates in CIS/eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service provided to a Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the Commonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, and access to services. External Quality Review Organization (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § 438.354, and performs EQR or other EQR-related activities as set forth in 42 C.F.R. § 438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined in 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned section of the SSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and cost. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHC-MCO, a subcontractor, a Provider, or a Participant. Grievance — A request to have the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary An individual who is enrolled in Medicareboth Medicare and MA. Dual Eligible Special Needs Plan (D-SNP) — – A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to both Medicare and Medicaid. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, . An Eligibility Period is indicated by the eligibility start and end dates in CIS/eCIS, and a . A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, pain such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in or with respect to a pregnant woman, the health of the woman or her unborn child, child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next business day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service covered healthcare service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment compensation regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date Expanded Services — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Any Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA▇▇▇, 42 U.S.C. ▇▇ ▇.▇.▇. §§ 1396 ▇▇▇▇ et seq., but not included in the CommonwealthState’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, timeliness and access to services. External Quality Review Organization (EQRO) — - An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § CFR §438.354, and performs EQR or as well as other EQR-related activities as set forth in 42 C.F.R. § CFR §438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children, children and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined in 42 U.S.C. § 1396d(lunder the Social ▇▇▇▇▇▇▇▇ ▇▇▇, ▇▇ ▇.▇.▇. ▇▇▇▇▇(▇) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned section sections of the SSAAct. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and costcost for the CHC- MCO Participants. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or personentity, him/herself, or some other person in a managed care setting, . The Fraud can be committed by any entitymany entities, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have the a CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity andand appropriateness of a healthcare service. A Grievance may be filed regarding a CHC-MCO decision to 1) deny, in whole or in part, payment for a service/item;

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary An individual who is enrolled in Medicareboth Medicare and MA. Dual Eligible Special Needs Plan (D-SNP) — – A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to both Medicare and MA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, . An Eligibility Period is indicated by the eligibility start and end dates in CIS/eCIS, and a . A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, pain such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in or with respect to a pregnant woman, the health of the woman or her unborn child, child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next business day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service covered healthcare service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment compensation regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date Expanded Services — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Any Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the CommonwealthState’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, timeliness and access to services. External Quality Review Organization (EQRO) — - An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § CFR §438.354, and performs EQR or as well as other EQR-related activities as set forth in 42 C.F.R. § CFR §438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children, children and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined in under the Social Security Act, 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned section sections of the SSAAct. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and costcost for the CHC- MCO Participants. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or personentity, him/herself, or some other person in a managed care setting, . The Fraud can be committed by any entitymany entities, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll Grievance — A request to have the a CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity andand appropriateness of a healthcare service. A Grievance may be filed regarding a CHC-MCO decision to 1) deny, in whole or in part, payment for a service/item;

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary who is enrolled in Medicare. Dual Eligible Special Needs Plan (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are enrolled in both Medicare and MA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, indicated by the eligibility start and end dates in CIS/eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s medical and non-medical needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events, including failure of individualized back-up plans during emergency events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service provided to a Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the Commonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, and access to services. External Quality Review Organization (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § 438.354, and performs EQR or other EQR-related activities as set forth in 42 C.F.R. § 438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services Diagnosis, treatment, drugs, supplies, and related counseling which are provided to individuals of child-bearing age to enable the individuals voluntarily to determine family size, to space freely the number and spacing of their children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which individual health center site location that is receiving a grant as defined in 42 U.S.C. § 1396d(l) receiving, or is receiving funding from such a grant under a contract with the recipient meets all of such a grant, and meets the requirements to receive a (FQHC “look alike”), grant funds under the above-mentioned section Sections 329, 330, 340, or 340A of the SSA. Public Health Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and costcost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHC-MCO, a subcontractor, a Provider, or a Participant. Grievance — A request to an MA Managed Care Plan by a Participant or a health care provider (with the written consent of the Participant), or a Participant’s authorized representative to have the CHC-MCO or utilization review entity an MA Managed Care Plan reconsider a decision solely concerning the Medical Necessity andmedical necessity, appropriateness, health care setting, level of care or effectiveness of a health care service. If the MA Managed Care Plan is unable to resolve the matter, a grievance may be filed regarding the decision that:

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary who is enrolled in Medicare. Dual Eligible Special Needs Plan (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are enrolled in both Medicare and MA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, indicated by the eligibility start and end dates in CIS/eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service provided to a Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the Commonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, and access to services. External Quality Review Organization (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § 438.354, and performs EQR or other EQR-related activities as set forth in 42 C.F.R. § 438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined in 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned section of the SSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and costcost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHC-MCO, a subcontractor, a Provider, or a Participant. Grievance — A request to have the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity andand appropriateness of a Covered Service. A Grievance may be filed regarding the CHC-MCO’s decision to 1) deny, in whole or in part, payment for a service/item;

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary who is enrolled in Medicare. Dual Eligible Special Needs Plan (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are enrolled in both Medicare and MA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, indicated by the eligibility start and end dates in CIS/eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service provided to a Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the Commonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, and access to services. External Quality Review Organization (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § 438.354, and performs EQR or other EQR-related activities as set forth in 42 C.F.R. § 438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services Diagnosis, treatment, drugs, supplies, and related counseling which are provided to individuals of child-bearing age to enable the individuals voluntarily to determine family size, to space freely the number and spacing of their children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which individual health center site location that is receiving a grant as defined in 42 U.S.C. § 1396d(l) receiving, or is receiving funding from such a grant under a contract with the recipient meets all of such a grant, and meets the requirements to receive a (FQHC “look alike”), grant funds under the above-mentioned section Sections 329, 330, 340, or 340A of the SSA. Public Health Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and costcost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHC-MCO, a subcontractor, a Provider, or a Participant. Grievance — A request to have the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity andand appropriateness of a Covered Service. A Grievance may be filed regarding the CHC-MCO’s decision to 1) deny, in whole or in part, payment for a service/item;

Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education, and outpatient care; and that includes evaluation of the appropriateness of the scope, setting, and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — A Beneficiary who is enrolled in Medicare. Dual Eligible Special Needs Plan (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are enrolled in both Medicare and MA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits, indicated by the eligibility start and end dates in CIS/eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or, in respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, the resolution of which should occur immediately or before the beginning of the next day in order to prevent a denial or significant delay in care to the Participant that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any Covered Service provided to a Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Service — A Medically Necessary service provided to a Participant which is covered under Title XIX of the SSA, 42 U.S.C. §§ 1396 et seq., but not included in the Commonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness, and access to services. External Quality Review Organization (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 C.F.R. § 438.354, and performs EQR or other EQR-related activities as set forth in 42 C.F.R. § 438.358, or both. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined in 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned section of the SSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and cost. Fraud — Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHC-MCO, a subcontractor, a Provider, or a Participant. Grievance — A request to have the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity andand appropriateness of a Covered Service. A Grievance may be filed regarding the CHC-MCO’s decision to 1) deny, in whole or in part, payment for a service/item;