Third Party Liability (TPL). The legal obligation of a third party (other than Medicaid) to pay for part or all of a claim. Since Medicaid is legally the “payer of last resort,” the identification of other payer obligations is a major requirement in the adjudication of claims. Trade Secret: Per Wis. Stat. 134.90(1), trade secrets are information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply: • 134.90(1)(c)1.1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use. • 134.90(1)(c)2.2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances. Trading Partner: Refers to a provider or PIHP that transmits any health information in electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. Transaction: The exchange of information between two parties to carry out financial or administrative activities related to health care as defined by 45 CFR Part 160.103. Transitional Care: Processes to ensure continuity of care that include, but are not limited to, medication reconciliation, ensuring members have a comprehensive understanding of their treatment plan, and assisting members with scheduling follow-up appointments with their primary care provider or specialists as needed after a member is discharged from an emergency department, hospital, nursing home, or rehabilitation facility or when a member is leaving out of home care or leaving the Xxxxxx Care Medical Home. Per 42 CFR § 438.208(b)(2), processes to coordinate services the PIHP furnishes to the member between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays. Trauma-informed Care: An approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. Urgent care/service needs: Services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services are often but not always those that if not fulfilled could result in an emergency room visit or inpatient admission. Validation: Per 42 CFR §438.320, the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis. Voluntary: Refers to situations where the Department cannot or does not require Medicaid members to enroll in a PIHP. Waste: The unnecessary incurrence of costs as a result of inefficient or inaccurate practices, systems or controls. Wisconsin Statewide Health Information Network (WISHIN): Wisconsin’s health information network that shares electronic health information securely between participating physicians, clinics, hospitals, pharmacies, clinical laboratories, and Health Maintenance Organizations (HMOs) across the state. Wisconsin Tribal Health Directors Association (WTHDA): The coalition of all Wisconsin American Indian Tribal Health Departments. Per 42 CFR 438.10, the PIHP must use the definitions for managed care terminology found above when communicating with members to ensure consistency in the information provided to members. Terms that are not defined above shall have their primary meaning identified in Wis. Adm. Code DHS 101-108.
Appears in 1 contract
Samples: www.forwardhealth.wi.gov
Third Party Liability (TPL). The legal obligation of a third party (other than Medicaid) to pay for part or all of a claim. Since Medicaid is legally the “payer of last resort,” the identification of other payer obligations is a major requirement in the adjudication of claims. Trade Secret: Per Wis. Stat. 134.90(1), trade secrets are information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply: • 134.90(1)(c)1.1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use. • 134.90(1)(c)2.2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances. Trading Partner: Refers to a provider or PIHP that transmits any health information in electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. Transaction: The exchange of information between two parties to carry out financial or administrative activities related to health care as defined by 45 CFR Part 160.103. Transitional Care: Processes to ensure continuity of care that include, but are not limited to, medication reconciliation, ensuring members have a comprehensive understanding of their treatment plan, and assisting members with scheduling follow-up appointments with their primary care provider or specialists as needed after a member is discharged from an emergency department, hospital, nursing home, or rehabilitation facility or when a member is leaving out of home care or leaving the Xxxxxx Care Medical Home. Per 42 CFR § 438.208(b)(2), processes to coordinate services the PIHP HMO furnishes to the member between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays. Trauma-informed Care: An approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. Urgent care/service needs: Services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services are often but not always those that if not fulfilled could result in an emergency room visit or inpatient admission. Validation: Per 42 CFR §438.320, the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis. Voluntary: Refers to situations where the Department cannot or does not require Medicaid members to enroll in a PIHP. Waste: The unnecessary incurrence of costs as a result of inefficient or inaccurate practices, systems or controls. Wisconsin Statewide Health Information Network (WISHIN): Wisconsin’s health information network that shares electronic health information securely between participating physicians, clinics, hospitals, pharmacies, clinical laboratories, and Health Maintenance Organizations (HMOs) HMOs across the state. Wisconsin Tribal Health Directors Association (WTHDA): The coalition of all Wisconsin American Indian Tribal Health Departments. Per 42 CFR 438.10, the PIHP must use the definitions for managed care terminology found above when communicating with members to ensure consistency in the information provided to members. Terms that are not defined above shall have their primary meaning identified in Wis. Adm. Code DHS 101-108.
Appears in 1 contract
Samples: www.forwardhealth.wi.gov
Third Party Liability (TPL). The legal obligation of a third party (other than Medicaid) to pay for part or all of a claim. Since Medicaid is legally the “payer of last resort,” the identification of other payer obligations is a major requirement in the adjudication of claims. Trade Secret: Per Wis. Stat. 134.90(1), trade secrets are information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply: • 134.90(1)(c)1.1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use. • 134.90(1)(c)2.2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances. Trading Partner: Refers to a provider or PIHP that transmits any health information in electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. Transaction: The exchange of information between two parties to carry out financial or administrative activities related to health care as defined by 45 CFR Part 160.103. Transitional Care: Processes to ensure continuity of care that include, but are not limited to, medication reconciliation, ensuring members have a comprehensive understanding of their treatment plan, and assisting members with scheduling follow-up appointments with their primary care provider or specialists as needed after a member is discharged from an emergency department, hospital, nursing home, or rehabilitation facility or when a member is leaving out of home care or leaving the Xxxxxx Care Medical Home. Per 42 CFR § 438.208(b)(2), processes to coordinate services the PIHP furnishes to the member between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays. Trauma-informed Care: An approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. Urgent care/service needs: Services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services are often but not always those that if not fulfilled could result in an emergency room visit or inpatient admission. Validation: Per 42 CFR §438.320, the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis. Voluntary: Refers to situations where the Department cannot or does not require Medicaid members to enroll in a PIHP. Waste: The unnecessary incurrence of costs as a result of inefficient or inaccurate practices, systems or controls. Wisconsin Statewide Health Information Network (WISHIN): Wisconsin’s health information network that shares electronic health information securely between participating physicians, clinics, hospitals, pharmacies, clinical laboratories, and Health Maintenance Organizations (HMOs) across the state. Wisconsin Tribal Health Directors Association (WTHDA): The coalition of all Wisconsin American Indian Tribal Health Departments. Per 42 CFR 438.10, the PIHP must use the definitions for managed care terminology found above when communicating with members to ensure consistency in the information provided to members. Terms that are not defined above shall have their primary meaning identified in Wis. Adm. Code DHS 101-108.. B. Acronyms Acronym Meaning AA Affirmative Action AAAHC Accreditation Association for Ambulatory Health Care ACA Affordable Care Act ACOG American Congress of Obstetricians and Gynecologists ADRC Aging and Disability Resource Center ASAM American Society of Addiction Medicine ASO Administrative Service Organization BBM Bureau of Benefits Management BC or BC+ BadgerCare or BadgerCare Plus BRS Bureau of Rate Settings CAH Critical Access Hospital CAP Corrective Action Plan CBRF Community Based Residential Facility CCS Comprehensive Community Services CDPS Chronic Illness & Disability Payment System CEHRT Certified Electronic Health Record Technology CEO Chief Executive Officer CESA Cooperative Educational Service Agencies CFO Chief Financial Officer CFR Code of Federal Regulations CIP Community Integration Program CLA Childless Adult CLAS Culturally and Linguistically Appropriate Services CLIA Clinical Laboratory Improvement Amendment CMS Centers for Medicare and Medicaid Services COB Coordination of Benefits COP Community Options Program CPT Current Procedural Terminology CRC Civil Rights Compliance CRS Community Recovery Services CSA Child Support Agency CSP Community Support Program CY Calendar Year DATA Drug Addiction Treatment Act DHCAA Division of Health Care Access & Accountability DMCPS Division of Milwaukee Child Protective Services DMHSAS Division of Mental Health & Substance Abuse DMS Division of Medicaid Services DOT Directly Observed Therapy DQA Division of Quality Assurance DRG Diagnosis Related Groupings DSPS Department of Safety and Professional Services DSS Department of Social Services DVT Deep Vein Thrombosis EFT Electronic Funds Transfer EHR Electronic Health Record EPSDT Early and Periodic Screening, Diagnosis, and Treatment EQR External Quality Review EQRO External Quality Review Organization ERISA Employee Retirement Income Security Act FCMH Xxxxxx Care Medical Home FFS Fee for Service FPL Federal Poverty Level FQHC Federally Qualified Health Center FTP File Transfer Protocol FY Fiscal Year HCPCS Healthcare Common Procedure Coding System HEDIS Healthcare Effectiveness Data and Information Set HHS Federal Department of Health and Human Services HIF Health Insurance Fee HIPAA The Health Insurance Portability and Accountability Act HMO Health Maintenance Organization HNA Health Needs Assessment HPSA Health Professional Shortage Area ICD International Classification of Diseases IDSS Institute for Data, Systems, and Society IFSP Individualized Family Service Plan IHCP Indian Health Care Provider IIHI Individually Identifiable Health Information IMD Institutes for Mental Disease IRS Internal Revenue Service LAN Learning Action Network LEP Limited English Proficiency LTC Long Term Care MA Medical Assistance/Medicaid XXXX Medicaid Purchase Plan MAT Medication Assisted Treatment MCO Managed Care Organization MMIS Medicaid Management Information System MOU Memorandum of Understanding MY Measurement Year NAIC National Association of Insurance Commissioners NCQA National Committee for Quality Assurance NEMT Non-Emergency Medical Transportation NPI National Provider Identifier NQTL Non-Quantitative Treatment Limits NTS Narcotic Treatment Services OBMH Obstetric Medical Home OCI Office of the Commissioner of Insurance OIG Office of the Inspector General ONC Office of National Coordinator PACE Program of All-Inclusive Care for the Elderly PCP Primary Care Provider PE Pulmonary Embolism PHI Protected Health Information PIHP PrePaid Inpatient Health Plan PIP Performance Improvement Project PNCC Prenatal Care Coordination PPACA Patient Protection Affordable Care Act PPR Potentially Preventable Readmissions P4P Pay for Performance QAPI Quality Assessment Performance Improvement RHC Rural Health Center SBS School Based Services SCHIP State Children’s Health Insurance Program SFTP Secure File Transfer Protocol SIU Special Investigations Unit SMV Specialized Medical Vehicles SSA Social Security Administration SSI Supplemental Security Income TCM Targeted Case Management TCOC Total Cost of Care TMSIS Transformed Medicaid Statistical Information System TPL Third Party Liability UM Utilization Management URAC Utilization Review Accreditation Commission VFC Vaccines for Children WCAG Web Content Accessibility Guidelines WIC Women, Infant, and Children WICT Wisconsin Interdisciplinary Care Team WIR Wisconsin Immunization Registry WISHIN Wisconsin Statewide Health Information Network ARTICLE II II. ENROLLMENT AND DISENROLLMENT A. Enrollment
Appears in 1 contract
Samples: www.forwardhealth.wi.gov
Third Party Liability (TPL). The legal obligation of a third party (other than Medicaid) to pay for part or all of a claim. Since Medicaid is legally the “payer of last resort,” the identification of other payer obligations is a major requirement in the adjudication of claims. Trade Secret: Per Wis. Stat. 134.90(1), trade secrets are information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply: • 134.90(1)(c)1.1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use. • 134.90(1)(c)2.2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances. Trading Partner: Refers to a provider or PIHP that transmits any health information in electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. Transaction: The exchange of information between two parties to carry out financial or administrative activities related to health care as defined by 45 CFR Part 160.103. Transitional Care: Processes to ensure continuity of care that include, but are not limited to, medication reconciliation, ensuring members have a comprehensive understanding of their treatment plan, and assisting members with scheduling follow-up appointments with their primary care provider or specialists as needed after a member is discharged from an emergency department, hospital, nursing home, or rehabilitation facility or when a member is leaving out of home care or leaving the Xxxxxx Care Medical Home. Per 42 CFR § 438.208(b)(2), processes to coordinate services the PIHP furnishes to the member between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays. Trauma-informed Care: An approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. Urgent care/service needs: Services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services are often but not always those that if not fulfilled could result in an emergency room visit or inpatient admission. Validation: Per 42 CFR §438.320, the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis. Voluntary: Refers to situations where the Department cannot or does not require Medicaid members to enroll in a PIHP. Waste: The unnecessary incurrence of costs as a result of inefficient or inaccurate practices, systems or controls. Wisconsin Statewide Health Information Network (WISHIN): Wisconsin’s health information network that shares electronic health information securely between participating physicians, clinics, hospitals, pharmacies, clinical laboratories, and Health Maintenance Organizations (HMOs), and Prepaid Inpatient Health Plans (PIHPs) across the state. Wisconsin Tribal Health Directors Association (WTHDA): The coalition of all Wisconsin American Indian Tribal Health Departments. Per 42 CFR 438.10, the PIHP must use the definitions for managed care terminology found above when communicating with members to ensure consistency in the information provided to members. Terms that are not defined above shall have their primary meaning identified in Wis. Adm. Code DHS 101-108.
Appears in 1 contract
Samples: DHS Agreement
