Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily Membership File — An electronic file in a HIPAA compliant 834 format using data from DPW/CIS that is transmitted to the Managed Care Organization on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of the RFP and this Agreement. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Public Welfare (DPW) of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  Attributable to a mental or physical impairment or combination of mental or physical impairments.  Manifested before the individual attains age twenty-two (22).  Likely to continue indefinitely.  Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DPW Fair Hearing — A hearing conducted by the Department of Public Welfare, Bureau of Hearings and Appeals. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles — An individual who is eligible to receive services through both Medicare and the MA Program (Medicaid). Effective January 1, 2006, Dual Eligibles age twenty-one (21) and older, and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made available to persons under the age of twenty- one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, Third Party Resources, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO Member (including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a PH-MCO Member, regardless of whether it has an associated Claim. Encounter Data — A record of any covered health care service provided to a PH-MCO Member and includes Encounters reimbursed through Capitation, Fee- for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients in selecting the PH-MCO and Primary Care Practitioner (PCP) and in obtaining information regarding HealthChoices Physical and Behavioral Health Services and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review (EQR) — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for states to obtain an independent, external review body to perform an annual review of the quality of services furnished under state contracts with Managed Care Organizations, including the evaluation of quality outcomes, timeliness and access to services. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available without regard to marital status, age, sex or parenthood. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service (FFS) — Payment by the Department to Providers on a per- service basis for health care services provided to Recipients. Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members, as approved by the Department. Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including the PH-MCO, a subcontractor, a Provider, a State employee, or a Member, among others. Generally Accepted Accounting Principles (GAAP) — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the PH-MCO. This individual acts as the day to day manager of contractual and operational issues and works within the PH-MCO and with DPW to facilitate compliance, solve problems, and implement corrective action. The Government Liaison negotiates internal PH-MCO policy and operational issues. Grievance — A request to have a PH-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to

Appears in 4 contracts

Samples: Grant Agreement, Grant Agreement, Grant Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily Membership File — An electronic file in a HIPAA compliant 834 format using data from DPW/CIS that is transmitted to the Managed Care Organization on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of the RFP and this Agreement. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Public Welfare (DPW) of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DPW Fair Hearing — A hearing conducted by the Department of Public Welfare, Bureau of Hearings and Appeals. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles — An individual who is eligible to receive services through both Medicare and the MA Program (Medicaid). ~~Effective January 1, 2006,~~ Dual Eligibles age ~~twenty-one (21)~~ 21 and ~~older,~~ older and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made available to persons under the age of twenty- one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, Third Party Resources, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO Member (including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a PH-MCO Member, regardless of whether it has an associated Claim. Encounter Data — A record of any covered health care service provided to a PH-MCO Member and includes Encounters reimbursed through Capitation, Fee- for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients in selecting the PH-MCO and Primary Care Practitioner (PCP) and in obtaining information regarding HealthChoices Physical and Behavioral Health Services and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review (EQR) — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for states to obtain an independent, external review body to perform an annual review of the quality of services furnished under state contracts with Managed Care Organizations, including the evaluation of quality outcomes, timeliness and access to services. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available without regard to marital status, age, sex or parenthood. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service (FFS) — Payment by the Department to Providers on a per- service basis for health care services provided to Recipients. Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members, as approved by the Department. Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including the PH-MCO, a subcontractor, a Provider, a State employee, or a Member, among others. Generally Accepted Accounting Principles (GAAP) — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the PH-MCO. This individual acts as the day to day manager of contractual and operational issues and works within the PH-MCO and with DPW to facilitate compliance, solve problems, and implement corrective action. The Government Liaison negotiates internal PH-MCO policy and operational issues. Grievance — A request to have a PH-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to

Appears in 2 contracts

Samples: Healthchoices Agreement, contracts.patreasury.gov

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW/CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on ~~CIS~~eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, timeliness and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social ~~Xxxxxxxx Xxx~~Security Act, ~~00 X.X.X. 0000x(x~~42 U.S.C. 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider a ~~decision solely concerning~~ decisionconcerning the Medical Necessity and appropriateness of a ~~health care~~ covered service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item and 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 2 contracts

Samples: Healthchoices Agreement, Healthchoices Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, ~~moral~~moral , intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW~~CIS/~~CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS/eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, ~~timeliness~~ timelin ess and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider ~~a decision solely~~ an adverse benefit determination concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item. 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Grant Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW~~CIS/~~CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS/eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, ~~timeliness~~ timelin ess and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social ~~Xxxxxxxx Xxx~~Security Act, ~~00 X.X.X. 0000x(x~~42 U.S.C. 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider ~~a decision solely~~ an adverse benefit determination concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item. 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Grant Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily Membership File — An electronic file in a HIPAA compliant 834 format using data from DPW/CIS that is transmitted to the Managed Care Organization on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of the RFP and this Agreement. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Public Welfare (DPW) of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DPW Fair Hearing — A hearing conducted by the Department of Public Welfare, Bureau of Hearings and Appeals. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles — An individual who is eligible to receive services through both Medicare and the MA Program (Medicaid). Effective January 1, 2006, Dual Eligibles age twenty-one (21) and older, and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made available to persons under the age of twenty- one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, Third Party Resources, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO Member (including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a PH-MCO Member, regardless of whether it has an associated Claim. Encounter Data — A record of any covered health care service provided to a PH-MCO Member and includes Encounters reimbursed through Capitation, Fee- for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients in selecting the PH-MCO and Primary Care Practitioner (PCP) and in obtaining information regarding HealthChoices Physical and Behavioral Health Services and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review (EQR) — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for states to obtain an independent, external review body to perform an annual review of the quality of services furnished under state contracts with Managed Care Organizations, including the evaluation of quality outcomes, timeliness and access to services. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available without regard to marital status, age, sex or parenthood. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service (FFS) — Payment by the Department to Providers on a per- service basis for health care services provided to Recipients. Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members, as approved by the Department. Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including the PH-MCO, a subcontractor, a Provider, a State employee, or a Member, among others. Generally Accepted Accounting Principles (GAAP) — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the PH-MCO. This individual acts as the day to day manager of contractual and operational issues and works within the PH-MCO and with DPW to facilitate compliance, solve problems, and implement corrective action. The Government Liaison negotiates internal PH-MCO policy and operational issues. Grievance — A request to have a PH-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to

Appears in 1 contract

Samples: Grant Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, ~~moral~~moral , intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW~~CIS/~~CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s 's need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s 's ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department's Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS/eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ ' current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s 's coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s 's Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, ~~timeliness~~ timelin ess and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO's P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s 's primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider ~~a decision solely~~ an adverse benefit determination concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item. 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Grant Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily Membership File — An electronic file in a HIPAA compliant 834 format using data from DPW/CIS that is transmitted to the Managed Care Organization on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of the RFP and this Agreement. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Public Welfare (DPW) of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  Attributable to a mental or physical impairment or combination of mental or physical impairments.  Manifested before the individual attains age twenty-two (22).  Likely to continue indefinitely.  Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DPW Fair Hearing — A hearing conducted by the Department of Public Welfare, Bureau of Hearings and Appeals. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles — An individual who is eligible to receive services through both Medicare and the MA Program (Medicaid). ~~Effective January 1, 2006,~~ Dual Eligibles age ~~twenty-one (21)~~ 21 and ~~older,~~ older and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made available to persons under the age of twenty- one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, Third Party Resources, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO Member (including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a PH-MCO Member, regardless of whether it has an associated Claim. Encounter Data — A record of any covered health care service provided to a PH-MCO Member and includes Encounters reimbursed through Capitation, Fee- for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients in selecting the PH-MCO and Primary Care Practitioner (PCP) and in obtaining information regarding HealthChoices Physical and Behavioral Health Services and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review (EQR) — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for states to obtain an independent, external review body to perform an annual review of the quality of services furnished under state contracts with Managed Care Organizations, including the evaluation of quality outcomes, timeliness and access to services. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available without regard to marital status, age, sex or parenthood. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service (FFS) — Payment by the Department to Providers on a per- service basis for health care services provided to Recipients. Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members, as approved by the Department. Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including the PH-MCO, a subcontractor, a Provider, a State employee, or a Member, among others. Generally Accepted Accounting Principles (GAAP) — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the PH-MCO. This individual acts as the day to day manager of contractual and operational issues and works within the PH-MCO and with DPW to facilitate compliance, solve problems, and implement corrective action. The Government Liaison negotiates internal PH-MCO policy and operational issues. Grievance — A request to have a PH-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to

Appears in 1 contract

Samples: contracts.patreasury.gov

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW~~CIS/~~CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS/eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, ~~timeliness~~ timelin ess and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider ~~a decision solely~~ an adverse benefit determination concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item. 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Healthchoices Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, ~~moral~~moral , intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW~~CIS/~~CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS/eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, ~~timeliness~~ timelin ess and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social ~~Xxxxxxxx Xxx~~Security Act, ~~00 X.X.X. 0000x(x~~42 U.S.C. 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider ~~a decision solely~~ an adverse benefit determination concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item. 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Healthchoices Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily ~~Membership~~ 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from ~~DPW/CIS~~ eCIS that is transmitted to the ~~Managed Care Organization~~ PH-MCO on state ~~work~~ business days. ~~This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor~~Day — Indicates a calendar day unless specifically denoted otherwise. See Business Day. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or ~~approval pursuant to the terms~~ approval. Deliverables include, but are not limited to: operational policies and procedures, letters of ~~the RFP~~ agreement, Provider Agreements, Provider reimbursement methodology, coordination agreements, reports, tracking systems, required files, QM/UM documents, and ~~this Agreement~~referral systems. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of ~~Public Welfare (DPW)~~ Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. ~~DPW~~ DHS Fair Hearing — A hearing conducted by the ~~Department of Public Welfare,~~ Department’s Bureau of Hearings and Appeals. Drug Efficacy Study Implementation ~~(DESI)~~ — Drug products that have been classified as less-than-effective by the ~~Food and Drug Administration (~~FDA). Dual ~~Eligibles~~ Eligible — An individual who is eligible to receive services through both Medicare and the MA ~~Program~~ Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (~~Medicaid). Effective January 1~~a) can withstand repeated use (bis primarily and customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, ~~2006, Dual Eligibles age twenty-one~~ illness or injury (21d) can be reusable or removable and ~~older, and who have Medicare, Part D, will no longer participate~~ (e) is appropriate for use in ~~HealthChoices~~any setting in which normal life activities take place. Early and Periodic Screening, Diagnosis and Treatment ~~(EPSDT)~~ — Items and services which must be made available to persons under the age of ~~twenty-~~ twenty-one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on ~~CIS~~eCIS. A blank eligibility end date signifies an ~~open~~Open-ended Eligibility Period. Eligibility Verification System ~~(EVS)~~ — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, ~~Third Party Resources~~TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn ~~child)~~ child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO ~~Member (~~Member, including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — —Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a ~~PH-MCO~~ Member, regardless of whether it has an associated Claim. Encounter Data — A record of any ~~covered health care service provided to a PH-MCO Member and includes~~ Encounter, including Encounters reimbursed through Capitation, ~~Fee-~~ Fee-for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollee — A Medicaid beneficiary who is currently enrolled in a PH-MCO. Enrollee Encounter Data — The information relating to the receipt of any item(s) or service(s) by an enrollee under a contract between the State and a PH-MCO that is subject to the requirements of 42 C.F.R. §438.242 and 42 C.F.R. §438.818. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program ~~(EAP)~~ — The program that provides Enrollment Specialists to assist Recipients in selecting ~~the~~ a PH-MCO and ~~Primary Care Practitioner (PCP)~~ PCP and in obtaining information regarding HealthChoices ~~Physical and~~ Physical, Behavioral Health ~~Services~~ Services, Community HealthChoices long-term services and supports and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Equity — The residual interest in the assets of an entity that remains after deducting its liabilities. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review ~~(EQR)~~ — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. 1396u-2(c)(2) for ~~states to obtain an~~ independent, external review body to perform an annual review of the quality of services furnished ~~under state contracts with Managed Care Organizations~~by MCOs, including the evaluation of quality outcomes, timeliness and access to services. Extranet – An Intranet site that can be accessed by authorized internal and external users to enable information exchange securely over the Internet. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. ~~Such services are made available without regard to marital status, age, sex or parenthood~~Federally Qualified Health Maintenance Organization (HMO) — An HMO that CMS has determined is a qualified HMO under section 1310(d) of the PHS Act. Federally Qualified Health Center ~~(FQHC)~~ — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service ~~(FFS)~~ — Payment by the Department to Providers on a ~~per-~~ per-service basis for health care services provided to Recipients. Formulary — ~~An exclusive~~ A Department-approved list of ~~drug products for which the Contractor must provide coverage to its Members, as approved~~ outpatient drugs determined by the ~~Department~~PH-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the PH-MCO Members. Fraud — Any type of intentional deception or ~~misrepresentation~~ misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the ~~entity, him/herself~~entity or person, or some other person in a managed care setting~~. The Fraud can be~~ , committed by ~~many entities~~any entity, including the PH-MCO, a subcontractor, a Provider, ~~a State employee,~~ or a Member, among others. Generally Accepted Accounting Principles ~~(GAAP)~~ — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the ~~PH-~~PH- MCO. This individual acts as the day to day manager of ~~contractual~~ Agreement and operational issues and works within the PH-MCO and with ~~DPW~~ the Department to facilitate compliance, solve problems, and implement corrective action~~. The Government Liaison negotiates internal PH-MCO policy and operational issues~~. Grievance — A request to have a PH-MCO or utilization review entity reconsider a ~~decision solely concerning~~ decisionconcerning the Medical Necessity and appropriateness of a ~~health care~~ covered service. A Grievance may be filed regarding a PH-MCO decision toto 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative service/item and 5) deny a request for a BLE. This term does not include a Complaint.

Appears in 1 contract

Samples: Healthchoices Agreement

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population, and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse populations. Daily Membership File — An electronic file in a HIPAA compliant 834 format using data from DPW/CIS that is transmitted to the Managed Care Organization on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s PROMISe™ contractor. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant to the terms of the RFP and this Agreement. Denial of Services — Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Public Welfare (DPW) of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is:  • Attributable to a mental or physical impairment or combination of mental or physical impairments.  • Manifested before the individual attains age twenty-two (22).  • Likely to continue indefinitely.  • Manifested in substantial functional limitations in three or more of the following areas of life activity: – Self care; – Receptive and expressive language; – Learning; – Mobility; – Capacity for independent living; and – Economic self-sufficiency.  • Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in Developmental Disabilities if services are not provided. Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DPW Fair Hearing — A hearing conducted by the Department of Public Welfare, Bureau of Hearings and Appeals. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles — An individual who is eligible to receive services through both Medicare and the MA Program (Medicaid). Effective January 1, 2006, Dual Eligibles age twenty-one (21) and older, and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made available to persons under the age of twenty- one (21) upon a determination of medical necessity and required by federal law at 42 U.S.C. §1396d(r). Early Intervention Program — The provision of specialized services through family-centered intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation below the mean in standardized tests in one or more areas: cognitive development; physical development, including vision and hearing; language and speech development; psycho-social development; or self-help skills or has a diagnosed condition which may result in developmental delay. Eligibility Period — A period of time during which a consumer is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates on CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified organizations for automated verification of MA Recipients’ current and past (up to three hundred sixty-five [365] days) MA eligibility, PH-MCO Enrollment, PCP assignment, Third Party Resources, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such 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: (a) 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, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem of a PH-MCO Member (including problems related to whether an individual is a Member), the resolution of which should occur immediately or before the beginning of the next Business Day in order to prevent a denial or significant delay in care to the Member that could precipitate an Emergency Medical Condition or need for urgent care. Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered health care service provided to a PH-MCO Member, regardless of whether it has an associated Claim. Encounter Data — A record of any covered health care service provided to a PH-MCO Member and includes Encounters reimbursed through Capitation, Fee- for-Service, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Member’s coverage by a PH-MCO is initiated. Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients in selecting the PH-MCO and Primary Care Practitioner (PCP) and in obtaining information regarding HealthChoices Physical and Behavioral Health Services and service Providers. Enrollment Specialist — The individual responsible to assist Recipients with selecting a PH-MCO and PCP as well as providing information regarding Physical and Behavioral Health Services and service Providers under the HealthChoices Program. Expanded Services — Any Medically Necessary service, covered under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq., but not included in the State’s Medicaid Plan, which is provided to Members. Experimental Treatment — A course of treatment, procedure, device or other medical intervention that is not yet recognized by the professional medical community as an effective, safe and proven treatment for the condition for which it is being used. External Quality Review (EQR) — A requirement under Section 1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C. ~~1396u-2(c)(2~~1396(a)(30)(C) for states to obtain an independent, external review body to perform an annual review of the quality of services furnished under state contracts with Managed Care Organizations, including the evaluation of quality outcomes, timeliness and access to services. Family Planning Services — Services which enable individuals voluntarily to determine family size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available without regard to marital status, age, sex or parenthood. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections of the Act. Fee-for-Service (FFS) — Payment by the Department to Providers on a per- service basis for health care services provided to Recipients. Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members, as approved by the Department. Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a managed care setting. The Fraud can be committed by many entities, including the PH-MCO, a subcontractor, a Provider, a State employee, or a Member, among others. Generally Accepted Accounting Principles (GAAP) — A technical term in financial accounting. It encompasses the conventions, rules, and procedures necessary to define accepted accounting practice at a particular time. Government Liaison — The Department’s primary point of contact within the PH-MCO. This individual acts as the day to day manager of contractual and operational issues and works within the PH-MCO and with DPW to facilitate compliance, solve problems, and implement corrective action. The Government Liaison negotiates internal PH-MCO policy and operational issues. Grievance — A request to have a PH-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to

Appears in 1 contract

Samples: Healthchoices Agreement

Common use of Cultural Competency Clause in Contracts