Common use of Cultural Competency Clause in Contracts

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. 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: 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). Dual Eligibles age 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 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

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. 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: 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 21 twenty-one (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

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. 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: 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 21 twenty-one (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

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 CIS that is transmitted to the PH-MCO on state work days. This 834 Daily File includes TPL information and is transmitted via the Department’s MIS contractor. 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 and this Agreement. agreement, Provider 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: 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, 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 (Medicaid)Program. Dual Eligibles age 21 and older and who have Medicare, Part D, will no longer participate in HealthChoices. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Durable Medical Equipment — Items and services which must be made available to persons under Equipment furnished by a supplier or a home health agency that meets 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 infollowing conditions: (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 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 towithstand repeated use

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. 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 Human Services (DPWDHS) 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: 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 WelfareHuman Services, 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). Dual Eligibles age 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 A Department-approved list of drug products for which the Contractor must provide coverage to its Members, as approved outpatient drugs determined by the DepartmentPH-MCO’s Pharmacy and Therapeutics (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 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 DHS 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

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. 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: 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 21 twenty-one (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)(21396(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

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moralmoral , intellectual and behavioral characteristics of a community or population, and translate this understanding systematically Daily 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to enhance the effectiveness of health care delivery to diverse populationsPH-MCO on state business days. 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 Agreementreferral 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: 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). Dual Eligibles age 21 a) can withstand repeated use (bis primarily and older customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, illness or injury (d) can be reusable or removable and who have Medicare, Part D, will no longer participate (e) is appropriate for use in HealthChoicesany 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 openOpen-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 ResourcesTPR, 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 Organizationsby 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 parenthoodFederally 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 XxxSecurity Act, 00 X.X.X. 0000x(x42 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. 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’s P&T Committee to have a significant, a subcontractorclinically meaningful therapeutic advantage in terms of safety, a Providereffectiveness, a State employee, or a Member, among othersand cost for the PH-MCO Members. Fraud — 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 the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to—

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moral, intellectual intellectual, and behavioral characteristics of a community or population, and translate this understanding systematically Daily 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to enhance the effectiveness of health care delivery to diverse populationsCHIP-MCO on state business days. Deliverables — Those documents, records and reports required to be furnished to the Department for review and/or approval pursuant approval. Deliverables include but are not limited to the terms 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 Agreementreferral systems. Denial of Services — Any determination made by the PHCHIP-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 PHCHIP-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: 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 Memberan Enrollee’s ability to receive services from a PHCHIP-MCO is terminated. DPW DHS Fair Hearing — A hearing conducted by the Department of Public Welfare, Department’s Bureau of Hearings and AppealsAppeals for CHIP regarding an eligibility determination. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the Food and Drug Administration (FDA). Dual Eligibles Durable Medical Equipment — An individual who is eligible to receive services through both Medicare and Equipment furnished by a supplier or a home health agency that meets the MA Program (Medicaid). Dual Eligibles age 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 infollowing conditions: (a) placing the health of the individual can withstand repeated use (or with respect bis primarily and customarily used to serve a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or medical purpose (c) serious dysfunction of any bodily organ or part. Emergency Member Issue — A problem generally is not useful to an individual in the absence of a PH-MCO Member disability, illness or injury (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: (ad) are furnished by a Provider that is qualified to furnish such service under Title XIX of 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, reusable or a Member, among others. Generally Accepted Accounting Principles removable and (GAAPe) — A technical term is appropriate for use 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 toany setting in which normal life activities take place.

Cultural Competency. The ability of individuals, as reflected in personal and organizational responsiveness, to understand the social, linguistic, moralmoral , intellectual and behavioral characteristics of a community or population, and translate this understanding systematically Daily 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to enhance the effectiveness of health care delivery to diverse populationsPH-MCO on state business days. 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 Agreementreferral 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: 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). Dual Eligibles age 21 a) can withstand repeated use (bis primarily and older customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, illness or injury (d) can be reusable or removable and who have Medicare, Part D, will no longer participate (e) is appropriate for use in HealthChoicesany 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 openOpen-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 ResourcesTPR, 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 Organizationsby 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 parenthoodFederally 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. 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's P&T Committee to have a significant, a subcontractorclinically meaningful therapeutic advantage in terms of safety, a Providereffectiveness, a State employee, or a Member, among othersand cost for the PH-MCO Members. Fraud — 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 concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to—

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 Daily 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to enhance the effectiveness of health care delivery to diverse populationsPH-MCO on state business days. 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 Agreementreferral 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: 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). Dual Eligibles age 21 a) can withstand repeated use (bis primarily and older customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, illness or injury (d) can be reusable or removable and who have Medicare, Part D, will no longer participate (e) is appropriate for use in HealthChoicesany 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 openOpen-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 ResourcesTPR, 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 Organizationsby 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 parenthoodFederally 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 XxxSecurity Act, 00 X.X.X. 0000x(x42 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. 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’s P&T Committee to have a significant, a subcontractorclinically meaningful therapeutic advantage in terms of safety, a Providereffectiveness, a State employee, or a Member, among othersand cost for the PH-MCO Members. Fraud — 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 the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to—

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 Daily 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to enhance the effectiveness of health care delivery to diverse populationsPH-MCO on state business days. 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 Agreementreferral 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: 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). Dual Eligibles age 21 a) can withstand repeated use (bis primarily and older customarily used to serve a medical purpose (c) generally is not useful to an individual in the absence of an disability, illness or injury (d) can be reusable or removable and who have Medicare, Part D, will no longer participate (e) is appropriate for use in HealthChoicesany 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 openOpen-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 ResourcesTPR, 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 Organizationsby 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 parenthoodFederally 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. 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’s P&T Committee to have a significant, a subcontractorclinically meaningful therapeutic advantage in terms of safety, a Providereffectiveness, a State employee, or a Member, among othersand cost for the PH-MCO Members. Fraud — 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 the Medical Necessity and appropriateness of a health care service. A Grievance may be filed regarding a PH-MCO decision to—

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. 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: 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 21 twenty-one (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