Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: • The service, item, procedure or level of care will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. • The service, item, procedure or level of care will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. • The service, item, procedure or level of care will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age. Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Monthly834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — An MA-enrolled Provider that has a written Network Provider Agreement and participates in the PH-MCO’s Network to serve the PH-MCO’s members. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial ...
Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to or from any MA service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary (also referred to as Medical Necessity) — Compensable under the MA Program and meeting any one of the following standards: • Will, or is reasonably expected to, prevent the onset of an illness, condition or disability. • Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. • Will assist a Participant to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Participant and those functional capacities that are appropriate for Participants of the sameage. • Will provide the opportunity for a Participant receiving LTSS to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or her choice. Medicare — The federal health insurance program administered by CMS pursuant to 42 U.S.C. §§ 1395 et seq., covering almost all Americans sixty-five
Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to or from any MA service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary (also referred to as Medical Necessity) — Compensable under the MA Program and meeting any one of the following standards: Will, or is reasonably expected to, prevent the onset of an illness, condition or disability. Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. Will assist a Participant to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Participant and those functional capacities that are appropriate for Participants of the sameage. Will provide the opportunity for a Participant receiving LTSS to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or her choice. Medicare — The federal health insurance program administered by CMS pursuant to 42 U.S.C. §§ 1395 et seq., covering almost all Americans sixty-five
Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to or from any MA service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary (also referred to as Medical Necessity) — A Covered Service is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards: • The Covered Service will, or is reasonably expected to, prevent the onset of an illness, condition or disability. • The Covered Service will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. • The Covered Service will assist the Participant to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Participant and those functional capacities that are appropriate for Participants of the sameage. MIPPA Agreement – An agreement required under the MIPPA of 2008 between a D-SNP and a State Medicaid Agency which documents entities’ roles and responsibilities with regard to Dual Eligibles and describes the D- SNP’s responsibility to integrate and coordinate Medicare and Medicaid benefits. Monthly Participant File — An electronic file in a HIPAA compliant 834 format using data from CIS that is transmitted to the CHC-MCO on a monthly basis via the Department’s MIS contractor. Network — All contracted or employed Providers with the CHC-MCO who are providing Covered Services to Participants. Network Provider — A MA enrolled Healthcare Provider who has a written Provider Agreement with and is credentialed by a CHC-MCO and who participates in the CHC-MCO’s Network to serve CHC Participants. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A Provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the CHC-MCO’s Network. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH and enrolled in the MA Program. Nursing Facility Clinically Eligible – Having clinical needs that require the level of care provided in a Nursing Facility. Nursing Facility Ineligible – Having clinical needs that do not require the level of care provided in a Nursing Facility. ...
Medical Assistance Transportation Program. MBE -- Minority Business Enterprise. MCO -- Managed Care Organization. MDW -- Xxxxxxx Dallas Waiver. MIS -- Management Information System. NCQA -- National Committee for Quality Assurance. NPDB -- National Practitioner Data Bank. OBRA -- Omnibus Budget Reconciliation Act. OCYF -- Office of Children, Youth and Families. OIP -- Other Insurance Paid. OMAP -- Office of Medical Assistance Programs. OMHSAS -- Office of Mental Health and Substance Abuse Services. OMR -- Office of Mental Retardation. ORC -- Other Related Conditions. OSP -- Office of Social Programs. PARP -- Prior Authorization Review Panel. PBM -- Pharmacy Benefit Manager. PCP -- Primary Care Practitioner. PDA -- Pennsylvania Department of Aging. PERT -- Program Evaluation and Review Technique. PH -- Physical Health. PH-MCO -- Physical Health Managed Care Organization. PMPM -- Per Member, Per Month. QARI -- Quality Assurance Reform Initiative. QM -- Quality Management. QMC -- Quality Management Committee. QM/UMP -- Quality Management and Utilization Management Program. RBUC -- Reported But Unpaid Claim. RFP -- Request for Proposal. RHC - Rural Health Clinic RPAA -- Risk Pool Allocation Amount. RTF -- Residential Treatment Facility. SAP -- Statutory Accounting Principles. SERB -- Socially/Economically Restricted Business. SNU -- Special Needs Unit. SPR -- Systems Performance Review. SSA -- Social Security Act. SSI -- Supplemental Security Income. STD -- Sexually Transmitted Disease. TANF -- Temporary Assistance for Needy Families. TCM -- Targeted Case Management. TPL -- Third Party Liability. TTY -- Text Telephone Typewriter. UM -- Utilization Management. URCAP -- Utilization Review Criteria Assessment Process. U.S. DHHS -- United States Department of Health and Human Services. WBE -- Women's Business Enterprise. WIC -- Women's, Infants' and Children (Program).
