Material Adjustment Sample Clauses
Material Adjustment. An adjustment that, using reasonable actuarial judgment, has a significant impact on the development of the capitation payment such that its omission or misstatement could impact a determination whether the development of the capitation rate is consistent with generally accepted actuarial principles and practices.
Material Adjustment. An adjustment that, using reasonable actuarial judgment, has a significant impact on the development of the Capitation payment such that its omission or misstatement could impact a determination whether the development of the capitation rate is consistent with generally accepted actuarial principles and practices. Medicaid Eligibility Determination Automation — Part of the eCIS that automates the determination of Medicaid eligibility. Medical Assistance — The Medical Assistance Program authorized by Title XIX of the federal Social Security Act, 42 U.S.C. §§1396 et seq., and regulations promulgated thereunder, and 62 P.S. §§441.1 et seq. and regulations at 55 Pa. Code Chapters 1101 et seq.
Material Adjustment. Material adjustment is an adjustment that, using reasonable actuarial judgment, has a significant impact on the development of the capitation payment such that its omission or misstatement could impact a determination whether the development of the capitation rate is consistent with generally accepted actuarial principles and practices.
Material Adjustment. An adjustment that, using reasonable actuarial judgment, has a significant impact on the development of the Capitation payment such that its omission or misstatement could impact a determination whether the development of the capitation rate is consistent with generally accepted actuarial principles and practices. Medical Assistance — The Medical Assistance Program authorized by Title XIX of the federal Social Security Act, 42 U.S.C. §§1396 et seq., and regulations promulgated thereunder, and 62 P.S. §§441.1 et seq. and regulations at 55 Pa. Code Chapters 1101 et seq. Medically Necessary — A service or benefit that is compensable under the CHIP Program and if it meets any one of the following standards: Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on CHIP eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which an Enrollee is eligible. MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit Monthly 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the CHIP-MCO on a monthly basis. Network — All contracted or employed Providers in the CHIP-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity that has a network provider agreement with a CHIP-MCO or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s contract with a CHIP-MCO. A network provider is not a Subcontractor by virtue of the network provider agreement. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid or CHIP. Non-risk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 CFR §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH. OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by ▇▇▇▇▇▇▇▇▇ and their advocates or Providers according to CHIP-MCO...