Plan Submitted Transaction Records Sample Clauses

Plan Submitted Transaction Records displays the transaction submitted by MMPs; does not show results, but allows Plans to view a transaction paired with its generated replies.

Plan Submitted Transaction Records displays the transaction submitted by MMPs; does not show results, but allows Plans to view a transaction paired with its generated replies. Demonstration - The program, administered by CMS and SCDHHS for providing integrated care to Medicare-Medicaid Enrollees that is the subject of this Contract. Disenrollment – The process by which an Enrollee’s participation in the Demonstration is terminated. Reasons for Disenrollment include death, loss of eligibility for the Demonstration, or choice not to participate in the Demonstration. Disenrollment at the direction of the Enrollee may also be referred to as “Opt-Out.” Eligible Beneficiary — An individual who is eligible to enroll in the Demonstration but has not yet done so. This includes individuals who are enrolled in Medicare Part A and B and are receiving full Medicaid benefits, have no other comprehensive private or public health coverage, and who meet all other Demonstration eligibility criteria. In other materials including the CFR, such an individual is sometimes referred to as a “potential enrollee.” Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) 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 placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions, or serious dysfunction of any bodily organ or part. Emergency Services –Inpatient and outpatient services covered under this Contract that are furnished by a Provider qualified to furnish such services and that are needed to evaluate or stabilize an Enrollee’s Emergency Medical Condition. Employer of Record - A company or organization that is legally responsible for paying employees, including dealing with employee taxes, benefits, insurance, and payroll Encounter Data - The record of an Enrollee receiving any item(s) or service(s) provided through Medicaid or Medicare under a prepaid, capitated, or any other risk basis payment methodology submitted to CMS and the SCDHHS. This record must incorporate HIPAA security, privacy, and transaction standards and be submitted in the ASC X12N 837 format or any successor format. Enrollee — Any Eligible Beneficiary who is actually enrolle...