Operations Management Information System electronic (PROMISe™) — A claims processing and management system implemented by the Department of Public Welfare that supports the Fee- for-Service and Managed Care Medical Assistance delivery programs. Quality Management (QM) — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Recipient — A person eligible to receive Physical and/or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Recipient covered by the HealthChoices Program for one (1) calendar month. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Parties — Any entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices physical health contract with the Department. Residential Treatment Facility (RTF) — A facility licensed by the Department of Public Welfare that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO to determine whether services were delivered as prescribed and consistent with the PH- MCO’s payment policies and procedures. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed profess...
Operations Management Information System electronic (PROMISe™) — The Department’s current claims processing and management system that supports the FFS and managed care deliveryprograms. Quality Management/Quality Improvement (QM/QI) — An ongoing, objective, and systematic process of monitoring, evaluating, and improving the quality, appropriateness, and effectiveness of care. Readily Accessible — Electronic information and services which comply with modern accessibility standards such as section 508 guidelines, section 504 of the Rehabilitation Act, and W3C's Web Content Accessibility Guidelines (WCAG) 2.0 AA and successor versions. Rejected Claim — A non-claim that has erroneously been assigned aunique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the CHC-MCO or a CHC-MCO subcontractor and (1) performs some of the CHC-MCO or subcontracting CHC- MCO's management functions under contract or delegation; or (2) furnishes services to Participants under a written agreement; or (3) leases real property or sells materials to the CHC-MCO or CHC-MCO’s subcontractor at a cost of more than $2,500.00 during any year of this Agreement. Restraint — A Restraint can be physical or chemical. A physical restraint is any apparatus, appliance, device, or garment applied to or adjacent to a Participant’s body, which restricts or diminishes the Participant’s level of independence or freedom. A chemical restraint is a psychopharmacologic drug that is used for discipline or convenience and not required to treat medical symptoms. A device used to provide support for functional body position or proper balance or a device used for medical treatment, such as sand bags to limit movement after medical treatment, a wheelchair belt used for body positioning and support, or a helmet to prevent injury during seizure activity is not a restraint. Retrospective Review — A review conducted by the CHC-MCO to determine whether services were delivered as authorized and consistent with the CHC- MCO’s payment policies and procedures. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. Examples of routine care include immunizations, screenings, and physical exams. Seclusion — The involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving. Services My Way — The B...
Operations Management Information System electronic (PROMISe™) — The Department’s Medicaid Management Information System (MMIS) that supports the FFS and managed care delivery programs, or its successor system. Quality Management/Quality Improvement (QM/QI) — An ongoing, objective, and systematic process of monitoring, evaluating, and improving the quality, appropriateness, and effectiveness of care. Readily Accessible — Electronic information and services which comply with modern accessibility standards such as section 508 guidelines, section 504 of the Rehabilitation Act, and W3C's Web Content Accessibility Guidelines (WCAG) 2.0 AA and successor versions. Rejected Claim — A non-claim that has erroneously been assigned aunique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the CHC-MCO or a CHC-MCO subcontractor and (1) performs some of the CHC-MCO or subcontracting CHC- MCO's management functions under contract or delegation; or (2) furnishes services to Participants under a written agreement; or (3) leases real property or sells materials to the CHC-MCO or CHC-MCO’s subcontractor at a cost of more than $2,500.00 during any year of this Agreement. Restraint — A Restraint can be physical or chemical. • A physical restraint is any apparatus, appliance, device, or garment applied to or adjacent to a Participant’s body, which restricts or diminishes the Participant’s level of independence or freedom. • A chemical restraint is a psychopharmacologic drug that is used for discipline or convenience and not required to treat medical symptoms. • A device used to provide support for functional body position or proper balance or a device used for medical treatment, such as sand bags to limit movement after medical treatment, a wheelchair belt used for body positioning and support, or a helmet to prevent injury during seizure activity is not a restraint. Retrospective Review — A review conducted by the CHC-MCO to determine whether services were delivered as authorized and consistent with the CHC- MCO’s payment policies and procedures. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. Examples of routine care include immunizations, screenings, and physical exams. Seclusion — The involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving....
Operations Management Information System electronic (PROMISe™) — The Department’s current claims processing and management system that supports the FFS and Managed Care MA deliveryprograms. Quality Management/Quality Improvement — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Recipient — A person eligible to receive Physical and/or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Parties — An entity that is an Affiliate of the CHC-MCO or subcontracting CHC-MCO and (1) performs some of the CHC-MCO or subcontracting CHC-MCO's management functions under contract or delegation; or (2) furnishes services to Participants under a written agreement; or (3) leases real property or sells materials to the CHC-MCO or subcontracting CHC-MCO at a cost of more than $2,500.00 during any year of a CHC agreement with the Department. Restraint—A Restraint can be physical or chemical. • A physical restraint includes any apparatus, appliance, device or garment applied to or adjacent to a resident’s body, which restricts or diminishes the resident’s level of independence or freedom. • A chemical restraint includes psychopharmacologic drugs that are used for discipline or convenience and not required to treat medical symptoms. A device used to provide support for functional body position or proper balance and a device used for medical treatment, such as sand bags to limit movement after medical treatment, a wheelchair belt that is used for body positioning and support or a helmet for prevention of injury during seizure activity, are not considered mechanical restraints. Retrospective Review — A review conducted by the CHC-MCO to determine whether services were delivered as prescribed and consistent with the CHC- MCO’s payment policies and procedures. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. Examples of preventive and routine care include immunizations, screenings and physical exams. Seclusion – The involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving. Service Coordination – Activities to identify, coordinate and assist Particip...
Operations Management Information System electronic (PROMISe™) — A claims processing and management system implemented by the Department that supports the Fee-for-Service, Managed Care Medical Assistance and Healthy Pennsylvania delivery programs. Quality Assurance (QA) — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Region—The nine (9) separate ACA Rating Areas in Pennsylvania. Related Parties — Any entity that is an Affiliate of the PCO or subcontracting PCO and (1) performs some of the PCO or subcontracting PCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PCO or subcontracting PCO at a cost of more than $2,500.00 during any year of a PCO Agreement with the Department. Start Date--The first date on which Members are eligible for medical and behavioral health services under this Agreement, and on which the PCO s are operationally responsible and financially liable for the provision of services to Members. Subcapitation — A fixed per capita amount that is paid by the PCO to a Network Provider for each Member identified as being in their capitation group, whether or not the Member received medical services. Subcontract — Any contract between the PCO and an individual, business, university, governmental entity, or nonprofit organization to perform part or all of the PCO’s responsibilities under this Agreement. Exempt from this definition are salaried employees, utility agreements and Provider Agreements, which are not considered Subcontracts for the purpose of this Agreement.
Operations Management Information System electronic (PROMISe™) — The Department’s Medicaid Management Information System (MMIS) that supports the FFS and managed care delivery programs, or its successor system. Quality Management/Quality Improvement (QM/QI) — An ongoing, objective, and systematic process of monitoring, evaluating, and improving the quality, appropriateness, and effectiveness of care.
Operations Management Information System electronic (PROMISe™) — A claims processing and management system implemented by the Department of Human Services that supports the Fee-for- Service and Managed Care Medical Assistance delivery programs. Quality Management/Quality Improvement (QM/QI) — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Recipient — A person eligible to receive Physical and/or Behavioral Health Services under the Medical Assistance Program of the Commonwealth of Pennsylvania. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Parties — Any entity that is an Affiliate of the CHC-MCO or subcontracting CHC-MCO and (1) performs some of the CHC-MCO or subcontracting CHC-MCO's management functions under contract or delegation; or (2) furnishes services to Participants under a written agreement; or (3) leases real property or sells materials to the CHC-MCO or subcontracting CHC-MCO at a cost of more than $2,500.00 during any year of a CHC contract with the Department. Residential Treatment Facility (RTF) — A facility licensed by the Department of Human Services that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one
Operations Management Information System electronic (PROMISe™) — A claims processing and management system implemented by the Department of Human Services that supports the Fee-for-Service and Managed Care Medical Assistance delivery programs. Quality Management (QM) — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Recipient — A person eligible to receive Physical and/or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Group — The Recipient Group is the group to which a specific MA recipient is assigned for payment. The Recipient Groups to which a MA recipient can be assigned are found on Xxxxxxxx 0x. Recipient Month — One Recipient covered by the HealthChoices Program for one (1) calendar month. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Parties — Any entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices physical health contract with the Department. Residential Treatment Facility (RTF) — A facility licensed by the Department of Human Services that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO to determine whether services were delivered as prescribed and consistent with the PH- MCO’s payment policies and procedures. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which p...
