PATIENT CENTERED MEDICAL HOME. “a health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families and communities. A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician or physician practice that leads a multidisciplinary health team, which may include, but is not limited to, nurse practitioners (NP), nurses, physician assistants (PA), behavioral health providers, pharmacists, social workers, physical therapists, dental and eye care providers and dieticians to meet the needs of the patient in all aspects of preventive, acute, chronic care and end-of-life care using evidence- based medicine and technology. At the point in time that CMS includes the NP as a leader of the multidisciplinary health team, this state will automatically implement this change (§16-29 H-9 of the West Virginia State Code).” Patient Protection and Affordable Care Act (PPACA) – the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Periodicity Schedule – the requirements and frequency by which periodic screening services are provided and covered. Schedule must meet current standards of pediatric medical and dental practice and specify screening services applicable at each stage of the enrollee's life, beginning with a neonatal examination, up to the age at which an individual is no longer eligible for EPSDT services. Person Centered Service Planning Team (PCSPT) – a team formed when a member enrolled in the SED waiver turns fifteen (15) and that is responsible for developing measurable outcomes that guide the member toward transition or graduation from waiver enrollment. Persons with Special Health Care Needs (SHCN) – individuals who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that generally required by individuals in that age range. Physician Services – health care services that a licensed medical physician provides or coordinates. Post-stabilization Services – services subsequent to an emergency medical condition that a treating physician views as Medically Necessary after an enrollee’s condition has been stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition. Potential Enrollee – a Medicaid recipient who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO. Pregnant Women or Pregnancy-Related Services – all women receiving related services and services for other conditions that might complicate the pregnancy, unless specifically identified in the Medicaid State Plan as not being related to the pregnancy. This includes counseling for cessation of tobacco use and services during the postpartum period. The pregnancy period for which these services must be covered includes the prenatal period through the postpartum period (including the sixty (60)-day postpartum period following the end of pregnancy; see 42 CFR 440.210(a)(3).
Appears in 2 contracts
Samples: dhhr.wv.gov, dhhr.wv.gov
PATIENT CENTERED MEDICAL HOME. “a health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families and communities. A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician or physician practice that leads a multidisciplinary health team, which may include, but is not limited to, nurse practitioners (NP), nurses, physician assistants (PA), behavioral health providers, pharmacists, social workers, physical therapists, dental and eye care providers and dieticians to meet the needs of the patient in all aspects of preventive, acute, chronic care and end-of-life care using evidence- based medicine and technology. At the point in time that CMS includes the NP as a leader of the multidisciplinary health team, this state will automatically implement this change (§16-29 H-9 of the West Virginia State Code).” Patient Protection and Affordable Care Act (PPACA) – the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Periodicity Schedule – the requirements and frequency by which periodic screening services are provided and covered. Schedule must meet current standards of pediatric medical and dental practice and specify screening services applicable at each stage of the enrollee's life, beginning with a neonatal examination, up to the age at which an individual is no longer eligible for EPSDT services. Person Centered Service Planning Team (PCSPT) – a team formed when a member enrolled in the SED waiver turns fifteen (15) and that is responsible for developing measurable outcomes that guide the member toward transition or graduation from waiver enrollment. Persons with Special Health Care Needs (SHCN) – individuals who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that generally required by individuals in that age range. Physician Services – health care services that a licensed medical physician provides or coordinates. Post-stabilization Services – services subsequent to an emergency medical condition that a treating physician views as Medically Necessary after an enrollee’s condition has been stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition. Potential Enrollee – a Medicaid recipient who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO. Pregnant Women or Pregnancy-Related Services – all women receiving related services and services for other conditions that might complicate the pregnancy, unless specifically identified in the Medicaid State Plan as not being related to the pregnancy. This includes counseling for cessation of tobacco use and services during the postpartum period. The pregnancy period for which these services must be covered includes the prenatal period through the postpartum period (including the sixty (60)-day one year postpartum period following the end of pregnancy; see pregnancy covered under West Virginia Code § 9-5-12. Prescription Drug Coverage – health insurance that helps pay for prescription drugs and medications. Prescription drug coverage is not provided by the MCO. The Department provides outpatient prescription drug coverage directly to Medicaid enrollees. Prescription Drugs – drugs and medication that, by law, require a prescription. Primary Care Physician – a doctor who directly provides and coordinates health care services to MCO enrollees. Primary Care Provider (PCP) – a specific clinician responsible for treating and coordinating the health care needs of certain enrollees. Primary Services – basic or general health services rendered by general practitioners, family practitioners, internists, obstetricians, and pediatricians. Prior Authorization/Preauthorization – approval granted for payment purposes by the MCO for its active, specified enrollees, or the Medicaid Program to a provider to render specified services to a specified enrollee. Provider – an individual or entity that is engaged in the delivery of health services, or ordering or referring for those services, who meets the requirements of the West Virginia Medicaid Program and is enrolled in the MCO’s network. Provider Complaint – any verbal or written expression of dissatisfaction with any aspect of operations or activities of the MCO received by the MCO from a provider through any means regardless of whether the expression of dissatisfaction is resolved immediately, requires investigation and/or further actions, or does not require any remedial action. For purposes of MCO reporting, provider complaints include what may be referred to as “grievances.” Psychiatric Residential Treatment Facilities (PRTF) – a separate, standalone entity providing a range of comprehensive psychiatric services to treat the psychiatric condition of residents under age twenty-one (21) years on an inpatient basis under the direction of a physician. The purpose of such comprehensive services is to improve the resident’s condition or prevent further regression so that the services will no longer be needed. (42 CFR 440.210(a)(3§483.352, subpart D of part 441). Pulmonary Rehabilitation – individually tailored multidisciplinary approach to the rehabilitation of enrollees who have pulmonary disease. Qualified Residential Treatment Program (QRTP) – a specific category of a licensed non-xxxxxx family home setting with a trauma-informed treatment model that is designed to address the needs, including clinical needs as appropriate, of children with serious emotional or behavioral disorders or disturbances and, with respect to a child, is able to implement the treatment identified for the child by the required thirty (30) day assessment of the appropriateness of the the placement. Regulation – a Federal or State agency statement of general applicability designed to implement or interpret law, policy, or procedure. Rehabilitation Services and Devices – health care services and devices that help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because he was sick, hurt, or disabled including occupational therapy, speech therapy, and psychiatric rehabilitation services in inpatient and/ or outpatient settings. Request for Proposals (RFP) – a document, containing the specifications or scope of work and all contractual terms and conditions, which is used to solicit written bids. Residential Placement – an Out of Home Placement setting designed to meet the needs of children and youth with behavioral, emotional and mental health needs that prevent them from being able to reside in a less structured family home setting. A residential treatment facility offers a structured physical environment and a treatment program designed to help children improve their ability to function in multiple areas of life. Risk – the possibility of monetary loss or gain by the MCO resulting from service costs exceeding or being less than payments made to it by the Department. Routine Care – basic primary care services including the diagnosis and treatment of conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Serious Emotional Disturbance (SED) – a diagnosable mental, behavioral, or emotional disorder at any time during the past year of sufficient duration to meet diagnostic criteria specified within the Diagnostic Statistical Manual (DSM) and that resulted in functional impairment which substantially interfered with or limited the child’s role or functioning in family, school, or community activities. Serious Emotional Disturbance (SED) Waiver – a Medicaid home and community-based services waiver authorized under §1915(c) of the Social Security Act. The SED waiver provides additional services to those provided through the Medicaid State Plan to children from three (3) up to age twenty-one (21) with an SED. It allows the State to provide an array of home- and community-based services that enable children who would otherwise require institutionalization to remain in their home and community. Service Authorization – (also Prior Authorization); includes an enrollee’s request for the provision of a service. Skilled Nursing Care – services from licensed nurses in a enrollee’s own home or in a nursing home. Socially Necessary Services (SNS) – Services provided to improve relationships and social functioning, with the goal of preserving the individual’s tenure in the community or the integrity of the family or social system. Socially necessary services are interventions designed to maintain or establish safety, permanency and well-being for targeted populations. Special Investigation Unit (SIU) – a team of program integrity staff responsible for detecting, correcting and reporting fraud, waste and abuse across various categories or health care (provider fraud, member fraud and external fraud). Specialist – a provider who focuses on a specific kind of health care, such as a surgeon or a cardiologist. Start Date – the date the Contract for services becomes effective. Subcontract – any written agreement between the MCO and another party to fulfill any requirements of this Contract. Subcontractor – party contracting with the MCO to perform any services related to the requirements of this Contract. Subcontractors may include, without limitation, affiliates, subsidiaries, and affiliated and unaffiliated third parties. Subcontractor Monitoring Plan – a written plan describing how obligations, services, and functions performed by the MCO's Subcontractor will be reviewed to ensure that such obligations, services, and functions are performed to the same extent that they were performed by MCO. Supplemental Security Income (SSI) – a Federal income supplement program designed to help aged, blind, and disabled people with little or no income by providing cash to meet basic needs for food, clothing, and shelter. Systems Quality Assurance Plan – a written plan developed by the MCO that describes the processes, techniques, and tools that the MCO will use for assuring that the MCO information systems meet the Contract requirements. Targeted Case Management (TCM) – the coordination of services to ensure that eligible Medicaid enrollees have access to a full array of needed services including the appropriate medical, educational, or other services. TCM is responsible for identifying an enrollee’s problems, needs, strengths, and resources; coordinating services necessary to meet those needs; and monitoring the provision of necessary and appropriate services. This process is intended to assist enrollees and as appropriate, their families, in accessing services which are supportive, effective and cost efficient. TCM activities ensure that the changing needs of the Medicaid enrollee are addressed on an ongoing basis and that appropriate choices are provided from the widest array of options for meeting those needs. TCM is not a direct service. TCM is composed of a number of federally designated components: Needs assessment and Reassessment; Development and Revision of TCM Service Plan; Referral and Related Activities; and Monitoring and Follow-up.
Appears in 1 contract
Samples: Service Provider Agreement
PATIENT CENTERED MEDICAL HOME. “a health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families and communities. A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician or physician practice that leads a multidisciplinary health team, which may include, but is not limited to, nurse practitioners (NP), nurses, physician assistants (PA), behavioral health providers, pharmacists, social workers, physical therapists, dental and eye care providers and dieticians to meet the needs of the patient in all aspects of preventive, acute, chronic care and end-of-life care using evidence- based medicine and technology. At the point in time that CMS includes the NP as a leader of the multidisciplinary health team, this state will automatically implement this change (§16-29 H-9 of the West Virginia State Code).” Patient Protection and Affordable Care Act (PPACA) – the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Periodicity Schedule – the requirements and frequency by which periodic screening services are provided and covered. Schedule must meet current standards of pediatric medical and dental practice and specify screening services applicable at each stage of the enrollee's life, beginning with a neonatal examination, up to the age at which an individual is no longer eligible for EPSDT services. Person Centered Service Planning Team (PCSPT) – a team formed when a member enrolled in the SED CSED waiver turns fifteen (15) and that is responsible for developing measurable outcomes that guide the member toward transition or graduation from waiver enrollment. Persons with Special Health Care Needs (SHCN) – individuals who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that generally required by individuals in that age range. Physician Services – health care services that a licensed medical physician provides or coordinates. Post-stabilization Services – services subsequent to an emergency medical condition that a treating physician views as Medically Necessary after an enrollee’s condition has been stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition. Potential Enrollee – a Medicaid recipient who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO. Pregnant Women or Pregnancy-Related Services – all women receiving related services and services for other conditions that might complicate the pregnancy, unless specifically identified in the Medicaid State Plan as not being related to the pregnancy. This includes counseling for cessation of tobacco use and services during the postpartum period. The pregnancy period for which these services must be covered includes the prenatal period through the postpartum period (including the sixty (60)-day one year postpartum period following the end of pregnancy; see pregnancy covered under West Virginia Code § 9-5-12. Prescription Drug Coverage – health insurance that helps pay for prescription drugs and medications. Prescription drug coverage is not provided by the MCO. The Department provides outpatient prescription drug coverage directly to Medicaid enrollees. Prescription Drugs – drugs and medication that, by law, require a prescription. Primary Care Physician – a doctor who directly provides and coordinates health care services to MCO enrollees. Primary Care Provider (PCP) – a specific clinician responsible for treating and coordinating the health care needs of certain enrollees. Primary Services – basic or general health services rendered by general practitioners, family practitioners, internists, obstetricians, and pediatricians. Prior Authorization/Preauthorization – approval granted for payment purposes by the MCO for its active, specified enrollees, or the Medicaid Program to a provider to render specified services to a specified enrollee. Provider – an individual or entity that is engaged in the delivery of health services, or ordering or referring for those services, who meets the requirements of the West Virginia Medicaid Program and is enrolled in the MCO’s network. Provider Complaint – any verbal or written expression of dissatisfaction with any aspect of operations or activities of the MCO received by the MCO from a provider through any means regardless of whether the expression of dissatisfaction is resolved immediately, requires investigation and/or further actions, or does not require any remedial action. For purposes of MCO reporting, provider complaints include what may be referred to as “grievances.” Psychiatric Residential Treatment Facilities (PRTF) – a separate, standalone entity or a distinct part of the acute care general psychiatric hospital providing a range of comprehensive psychiatric services to treat the psychiatric condition of residents under age twenty-one (21) years on an inpatient basis under the direction of a physician. The purpose of such comprehensive services is to improve the resident’s condition or prevent further regression so that the services will no longer be needed. (42 CFR 440.210(a)(3§483.352, subpart D of part 441). Pulmonary Rehabilitation – individually tailored multidisciplinary approach to the rehabilitation of enrollees who have pulmonary disease. Qualified Residential Treatment Program (QRTP) – a specific category of a licensed non-xxxxxx family home setting with a trauma-informed treatment model that is designed to address the needs, including clinical needs as appropriate, of children with serious emotional or behavioral disorders or disturbances and, with respect to a child, is able to implement the treatment identified for the child by the required thirty (30) day assessment of the appropriateness of the placement. Regulation – a Federal or State agency statement of general applicability designed to implement or interpret law, policy, or procedure. Rehabilitation Services and Devices – health care services and devices that help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because he was sick, hurt, or disabled including occupational therapy, speech therapy, and psychiatric rehabilitation services in inpatient and/ or outpatient settings. Request for Proposals (RFP) – a document, containing the specifications or scope of work and all contractual terms and conditions, which is used to solicit written bids. Residential Placement – an Out of Home Placement setting designed to meet the needs of children and youth with behavioral, emotional and mental health needs that prevent them from being able to reside in a less structured family home setting. A residential treatment facility offers a structured physical environment and a treatment program designed to help children improve their ability to function in multiple areas of life. Risk – the possibility of monetary loss or gain by the MCO resulting from service costs exceeding or being less than payments made to it by the Department. Routine Care – basic primary care services including the diagnosis and treatment of conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Serious Emotional Disturbance (SED) – a diagnosable mental, behavioral, or emotional disorder at any time during the past year of sufficient duration to meet diagnostic criteria specified within the Diagnostic Statistical Manual (DSM) and that resulted in functional impairment which substantially interfered with or limited the child’s role or functioning in family, school, or community activities. Service Authorization – (also Prior Authorization); includes an enrollee’s request for the provision of a service. Skilled Nursing Care – services provided by trained registered nurses in a medical setting or enrollee’s own home under a doctor’s supervision. Socially Necessary Services (SNS) – Services provided to improve relationships and social functioning, with the goal of preserving the individual’s tenure in the community or the integrity of the family or social system. Socially necessary services are interventions designed to maintain or establish safety, permanency and well-being for targeted populations. Special Investigation Unit (SIU) – a team of program integrity staff responsible for detecting, correcting and reporting fraud, waste and abuse across various categories or health care (provider fraud, member fraud and external fraud). Specialist – a provider who focuses on a specific kind of health care, such as a surgeon or a cardiologist. Start Date – the date the Contract for services becomes effective. Subcontract – any written agreement between the MCO and another party to fulfill any requirements of this Contract. Subcontractor – party contracting with the MCO to perform any services related to the requirements of this Contract. Subcontractors may include, without limitation, affiliates, subsidiaries, and affiliated and unaffiliated third parties. Subcontractor Monitoring Plan – a written plan describing how the MCO will review obligations, services, and functions performed by the MCO's Subcontractor to ensure that such obligations, services, and functions are performed to the same extent that they would be if performed by MCO. Supplemental Security Income (SSI) – a Federal income supplement program designed to help aged, blind, and disabled people with little or no income by providing cash to meet basic needs for food, clothing, and shelter. Systems Quality Assurance Plan – a written plan developed by the MCO that describes the processes, techniques, and tools that the MCO will use for assuring that the MCO information systems meet the Contract requirements. Targeted Case Management (TCM) – the coordination of services to ensure that eligible Medicaid enrollees have access to a full array of needed services including the appropriate medical, educational, or other services. TCM is responsible for identifying an enrollee’s problems, needs, strengths, and resources; coordinating services necessary to meet those needs; and monitoring the provision of necessary and appropriate services. This process is intended to assist enrollees and as appropriate, their families, in accessing services which are supportive, effective and cost efficient. TCM activities ensure that the changing needs of the Medicaid enrollee are addressed on an ongoing basis and that appropriate choices are provided from the widest array of options for meeting those needs. TCM is not a direct service. TCM is composed of a number of federally designated components: Needs assessment and Reassessment; Development and Revision of TCM Service Plan; Referral and Related Activities; and Monitoring and Follow-up.
Appears in 1 contract
Samples: dhhr.wv.gov
PATIENT CENTERED MEDICAL HOME. “a health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families and communities. A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician or physician practice that leads a multidisciplinary health team, which may include, but is not limited to, nurse practitioners (NP)practitioners, nurses, physician assistants (PA)physician’s assistants, behavioral health providers, pharmacists, social workers, physical therapists, dental and eye care providers and dieticians to meet the needs of the patient in all aspects of preventive, acute, chronic care and end-of-life care using evidence- evidence-based medicine and technology. At the point in time that CMS the Center for Medicare and Medicaid Services includes the NP nurse practitioner as a leader of the multidisciplinary health team, this state will automatically implement this change (§16-29 H-9 of the West Virginia State Code).” Patient Protection and Affordable Care Act (PPACA) Participating Provider – a doctor, hospital, facility, or other licensed health care professional who has signed a contract or had a contract signed on his/her behalf agreeing to provide services to the MCO’s members. PPACA – the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), together known as the Affordable Care Act (ACA). Periodicity Schedule – the requirements and frequency by which periodic screening services are provided and covered. Schedule must meet current standards of pediatric medical and dental practice and specify screening services applicable at each stage of the enrolleerecipient's life, beginning with a neonatal examination, up to the age at which an individual is no longer eligible for EPSDT services. Person Centered Service Planning Team (PCSPT) – a team formed when a member enrolled in the SED waiver turns fifteen (15) and that is responsible for developing measurable outcomes that guide the member toward transition or graduation from waiver enrollment. Persons with Special Health Care Needs (SHCN) – individuals who have chronic physical, developmental, behavioral or emotional conditions. Such needs are of a type or amount beyond that generally required by individuals in that age range. Physician Services – health care services that a licensed medical physician provides or coordinates. Post-stabilization Services – services subsequent to an emergency medical condition that a treating physician views as Medically Necessary after an enrollee’s condition has been stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition. Potential Enrollee – a Medicaid recipient who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO. Pregnant Women or Pregnancy-Related Services – all women receiving related services and services for other conditions that might complicate the pregnancy, unless specifically identified in the Medicaid State Plan as not being related to the pregnancy. This includes counseling for cessation of tobacco use and services during the postpartum period. The pregnancy period for which these services must be covered includes the prenatal period through the postpartum period (including the sixty (60)-day postpartum period following the end of pregnancy; see 42 CFR 440.210(a)(3).
Appears in 1 contract
