Common use of Potential Participant Clause in Contracts

Potential Participant. An individual who either 1) is an Eligible Individual or is not yet an Eligible Individual but may become an Eligible Individual in the foreseeable future. Preadmission Screening and Resident Review – A Federally mandated process to determine whether individuals who have a Mental Illness, ID, or ORC require NF Services and if they also require Specialized Services to treat their conditions, based on the criteria established by CMS. The screening process applies to all individuals seeking admission to any MA-certified NF, regardless of payment source (private pay, third party insurance and/or MA). The PASRR process must be completed prior to admission and no later than the day of admission. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the CHC-MCO Participants by the CHC-MCO’s P&T Committee. Primary Care - Healthcare services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, or obstetrician/gynecologist acting within the scope of his/her licensure. Primary Care Practitioner— A specific physician, physician group or a CRNP operating under the scope of his or her licensure, who is responsible for supervising, prescribing, and providing Primary Care services; locating, coordinating and monitoring other medical care and rehabilitative services, and maintaining continuity of care on behalf of a Participant. Primary Care Practitioner Site — The location or office of a PCP where Participant care is delivered. Prior Authorization — A determination made by the CHC-MCO to approve or deny payment for a Provider's request to provide a Covered Service or course of treatment of a specific duration and scope to a Participant prior to the Provider's initiation or continuation of the requested service. Prior Authorized Services — Covered Services, determined to be Medically Necessary, the utilization of which the CHC-MCO manages in accordance with Department-approved Prior Authorization policies andprocedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — A licensed hospital or healthcare facility, medical equipment supplier, person, firm, corporation, or other entity who is licensed, certified or otherwise authorized to provide healthcare services under the laws of the Commonwealth or other states. The term includes but is not be limited to the following: physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, home care agency, durable medical equipment supplier, LTSS provider, or behavioral health service provider. Provider Agreement — A Department-approved written agreement between the CHC-MCO and a Provider to provide medical or professional services to Participants to fulfill the requirements of this agreement. Provider Appeal — A request from a Provider for reversal of a determination by the CHC-MCO of: • A Provider credentialing denial. • Claims denied by the CHC-MCO for Network Providers. • Provider Agreement termination. Provider Dispute — A written communication to a CHC-MCO, made by a Provider, expressing dissatisfaction with a CHC-MCO decision that directly impacts the Provider, excluding decisions concerning Medical Necessity. Provider-Preventable Condition — A condition that meets the definition of a HCAC or other provider-preventable condition as defined in 42 CFR§ 447.26(b).

Potential Participant. An individual who either 1) is an Eligible Individual or is not yet an Eligible Individual but may become an Eligible Individual in the foreseeable future. Preadmission Screening and Resident Review – A Federally mandated process to determine whether individuals who have a Mental Illness, ID, or ORC require NF Services and if they also require Specialized Services to treat their conditions, based on the criteria established by CMS. The screening process applies to all individuals seeking admission to any MA-certified NF, regardless of payment source (private pay, third party insurance and/or MA). The PASRR process must be completed prior to admission and no later than the day of admission. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the CHC-MCO Participants by the CHC-MCO’s P&T Committee. Primary Care - Healthcare services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, or obstetrician/gynecologist acting within the scope of his/her licensure. Primary Care Practitioner— A specific physician, physician group or a CRNP operating under the scope of his or her licensure, who is responsible for supervising, prescribing, and providing Primary Care services; locating, coordinating and monitoring other medical care and rehabilitative services, and maintaining continuity of care on behalf of a Participant. Primary Care Practitioner Site — The location or office of a PCP where Participant care is delivered. Prior Authorization — A determination made by the CHC-MCO to approve or deny payment for a Provider's request to provide a Covered Service or course of treatment of a specific duration and scope to a Participant prior to the Provider's initiation or continuation of the requested service. Prior Authorized Services — Covered Services, determined to be Medically Necessary, the utilization of which the CHC-MCO manages in accordance with Department-approved Prior Authorization policies andprocedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — A licensed hospital or healthcare facility, medical equipment supplier, person, firm, corporation, or other entity who is licensed, certified or otherwise authorized to provide healthcare services under the laws of the Commonwealth or other states. The term includes but is not be limited to the following: physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, home care agency, durable medical equipment supplier, LTSS provider, or behavioral health service provider. Provider Agreement — A Department-approved written agreement between the CHC-MCO and a Provider to provide medical or professional services to Participants to fulfill the requirements of this agreementthisagreement. Provider Appeal — A request from a Provider for reversal of a determination by the CHC-MCO of: • A Provider credentialing denial. • Claims denied by the CHC-MCO for Network Providers. • Provider Agreement termination. Provider Dispute — A written communication to a CHC-MCO, made by a Provider, expressing dissatisfaction with a CHC-MCO decision that directly impacts the Provider, excluding decisions concerning Medical Necessity. Provider-Preventable Condition — A condition that meets the definition of a HCAC or other provider-preventable condition as defined in 42 CFR§ 447.26(b).

Potential Participant. An individual who either 1) is an Eligible Individual or is not yet an Eligible Individual but may become an Eligible Individual in the foreseeable future. Preadmission Screening and Resident Review – A Federally mandated process to determine whether individuals who have a Mental Illness, ID, or ORC require NF Services and if they also require Specialized Services to treat their conditions, based on the criteria established by CMS. The screening process applies to all individuals seeking admission to any MA-certified NF, regardless of payment source (private pay, third party insurance and/or MA). The PASRR process must be completed prior to admission and no later than the day of admission. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the CHC-MCO Participants by the CHC-MCO’s P&T Committee. Primary Care - Healthcare services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, or obstetrician/gynecologist acting within the scope of his/her licensure. Primary Care Practitioner— A specific physician, physician group or a CRNP operating under the scope of his or her licensure, who is responsible for supervising, prescribing, and providing Primary Care services; locating, coordinating and monitoring other medical care and rehabilitative services, and maintaining continuity of care on behalf of a Participant. Primary Care Practitioner Site — The location or office of a PCP where Participant care is delivered. Prior Authorization — A determination made by the CHC-MCO to approve or deny payment for a Provider's request to provide a Covered Service or course of treatment of a specific duration and scope to a Participant prior to the Provider's initiation or continuation of the requested service. Prior Authorized Services — Covered Services, determined to be Medically Necessary, the utilization of which the CHC-MCO manages in accordance with Department-approved Prior Authorization policies andprocedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — A licensed hospital or healthcare facility, medical equipment supplier, person, firm, corporation, or other entity who is licensed, certified or otherwise authorized to provide healthcare services under the laws of the Commonwealth or other states. The term includes but is not be limited to the following: physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, home care agency, durable medical equipment supplier, LTSS provider, or behavioral health service provider. Provider Agreement — A Department-approved written agreement between the CHC-MCO and a Provider to provide medical or professional services to Participants to fulfill the requirements of this agreement. Provider Appeal — A request from a Provider for reversal of a determination by the CHC-MCO of: •  A Provider credentialing denial. •  Claims denied by the CHC-MCO for Network Providers. •  Provider Agreement termination. Provider Dispute — A written communication to a CHC-MCO, made by a Provider, expressing dissatisfaction with a CHC-MCO decision that directly impacts the Provider, excluding decisions concerning Medical Necessity. Provider-Preventable Condition — A condition that meets the definition of a HCAC or other provider-preventable condition as defined in 42 CFR§ 447.26(b).

Potential Participant. An individual who either 1) is an Eligible Individual or is not yet an Eligible Individual but may become an Eligible Individual in the foreseeable future. Preadmission Screening and Resident Review – A Federally mandated process to determine whether individuals who have a Mental Illness, ID, or ORC require NF Services and if they also require Specialized Services to treat their conditions, based on the criteria established by CMS. The screening process applies to all individuals seeking admission to any MA-certified NF, regardless of payment source (private pay, third party insurance and/or MA). The PASRR process must be completed prior to admission and no later than the day of admission. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the CHC-MCO Participants by the CHC-MCO’s P&T Committee. Primary Care - Healthcare services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, or obstetrician/gynecologist acting within the scope of his/her licensure. Primary Care Practitioner— A specific physician, physician group or a CRNP operating under the scope of his or her licensure, who is responsible for supervising, prescribing, and providing Primary Care services; locating, coordinating and monitoring other medical care and rehabilitative services, and maintaining continuity of care on behalf of a Participant. Primary Care Practitioner Site — The location or office of a PCP where Participant care is delivered. Prior Authorization — A determination made by the CHC-MCO to approve or deny payment for a Provider's request to provide a Covered Service or course of treatment of a specific duration and scope to a Participant prior to the Provider's initiation or continuation of the requested service. Prior Authorized Services — Covered Services, determined to be Medically Necessary, the utilization of which the CHC-MCO manages in accordance with Department-approved Prior Authorization policies andprocedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — A licensed hospital or healthcare facility, medical equipment supplier, person, firm, corporation, or other entity who is licensed, certified or otherwise authorized to provide healthcare services under the laws of the Commonwealth or other states. The term includes but is not be limited to the following: physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, home care agency, durable medical equipment supplier, LTSS provider, or behavioral health service provider. Provider Agreement — A Department-approved written agreement between the CHC-MCO and a Provider to provide medical or professional services to Participants to fulfill the requirements of this agreementthisagreement. Provider Appeal — A request from a Provider for reversal of a determination by the CHC-MCO of: •  A Provider credentialing denial. •  Claims denied by the CHC-MCO for Network Providers. •  Provider Agreement termination. Provider Dispute — A written communication to a CHC-MCO, made by a Provider, expressing dissatisfaction with a CHC-MCO decision that directly impacts the Provider, excluding decisions concerning Medical Necessity. Provider-Preventable Condition — A condition that meets the definition of a HCAC or other provider-preventable condition as defined in 42 CFR§ 447.26(b).