Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual who is enrolled in both Medicare and MA. Dual Eligible Special Needs Plan – A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to both Medicare and Medicaid. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates in CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 healthcare service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Expanded Services — Any Medically Necessary service provided to a Participant which is covered under Title XIX of the XXX, 00 X.X.X. §0000 et seq., but not included in the State’s Medicaid Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness and access to services. External Quality Review Organization - An independent organization that meets the competence and independence requirements set forth in 42 CFR §438.354, and performs EQR as well as other EQR-related activities as set forth in 42 CFR §438.358, or both. 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. Federally Qualified Health Center — 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 — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. 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 CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare service. A Grievance may be filed regarding a CHC-MCO decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Samples: Community Healthchoices Agreement
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual who is enrolled in both Medicare and MA. Dual Eligible Special Needs Plan – A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates in CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 healthcare service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Expanded Services — Any Medically Necessary service provided to a Participant which is covered under Title XIX of the XXX, 00 X.X.X. §0000 et seq., but not included in the State’s Medicaid Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness and access to services. External Quality Review Organization - An independent organization that meets the competence and independence requirements set forth in 42 CFR §438.354, and performs EQR as well as other EQR-related activities as set forth in 42 CFR §438.358, or both. 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. Federally Qualified Health Center — 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 — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. 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 CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare service. A Grievance may be filed regarding a CHC-MCO decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Samples: Community Healthchoices Agreement
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual A Beneficiary who is enrolled in both Medicare and MAMedicare. Dual Eligible Special Needs Plan – (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to enrolled in both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is , indicated by the eligibility start and end dates in CIS. A eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain 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 or, in 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 Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered healthcare service Covered Service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Services Service — Any A Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 § 1396 et seq., but not included in the StateCommonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness timeliness, and access to services. External Quality Review Organization - (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 CFR §C.F.R. § 438.354, and performs EQR as well as or other EQR-related activities as set forth in 42 CFR §C.F.R. § 438.358, or both. 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 children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(xin 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections section of the ActSSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herselfentity or person, or some other person in a managed care setting. The Fraud can be , committed by many entitiesany entity, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare serviceCovered Service. A Grievance may be filed regarding a the CHC-MCO MCO’s decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual A Beneficiary who is enrolled in both Medicare and MAMedicare. Dual Eligible Special Needs Plan – (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to enrolled in both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is , indicated by the eligibility start and end dates in CIS. A , and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain 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 or, in 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 Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered healthcare service Covered Service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Services Service — Any A Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 § 1396 et seq., but not included in the StateCommonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness timeliness, and access to services. External Quality Review Organization - (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 CFR §C.F.R. § 438.354, and performs EQR as well as or other EQR-related activities as set forth in 42 CFR §C.F.R. § 438.358, or both. 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 children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(xin 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections section of the ActSSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and cost for the CHC- MCO Participantscost. Fraud — Any type of intentional deception or misrepresentation misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herselfentity or person, or some other person in a managed care setting. The Fraud can be , committed by many entitiesany entity, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare serviceCovered Service. A Grievance may be filed regarding a the CHC-MCO MCO’s decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual A Beneficiary who is enrolled in both Medicare and MAMedicare. Dual Eligible Special Needs Plan – (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to enrolled in both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is , indicated by the eligibility start and end dates in CIS. A /eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain 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 or, in 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 Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered healthcare service Covered Service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Services Service — Any A Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 § 1396 et seq., but not included in the StateCommonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness timeliness, and access to services. External Quality Review Organization - (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 CFR §C.F.R. § 438.354, and performs EQR as well as or other EQR-related activities as set forth in 42 CFR §C.F.R. § 438.358, or both. 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 children, and to prevent or reduce the incidence of unplanned pregnancies. Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social Xxxxxxxx Xxx, 00 X.X.X. 0000x(xin 42 U.S.C. § 1396d(l) or is receiving funding from such a grant under a contract with the recipient of such a grant, and meets the requirements to receive a grant under the above-mentioned sections section of the ActSSA. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage over other outpatient drugs in the same class in terms of safety, effectiveness, and cost for the CHC- MCO Participantscost. Fraud — Any type of intentional deception or misrepresentation misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herselfentity or person, or some other person in a managed care setting. The Fraud can be , committed by many entitiesany entity, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare serviceCovered Service. A Grievance may be filed regarding a the CHC-MCO MCO’s decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Samples: Community Healthchoices Agreement
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual A Beneficiary who is enrolled in both Medicare and MAMedicare. Dual Eligible Special Needs Plan – (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to enrolled in both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is , indicated by the eligibility start and end dates in CIS. A eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s medical and non-medical needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events, including failure of individualized back-up plans during emergency events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain 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 or, in 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 Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered healthcare service Covered Service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Services Service — Any A Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 § 1396 et seq., but not included in the StateCommonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness timeliness, and access to services. External Quality Review Organization - (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 CFR §C.F.R. § 438.354, and performs EQR as well as or other EQR-related activities as set forth in 42 CFR §C.F.R. § 438.358, or both. 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 Diagnosis, treatment, drugs, supplies, and related counseling which are provided to individuals of child-bearing age to enable the individuals voluntarily to determine family size, to space children freely the number and to prevent or reduce the incidence spacing of unplanned pregnanciestheir children. Federally Qualified Health Center (FQHC) — An entity which individual health center site location that is receiving a grant as defined under the Social Xxxxxxxx Xxxreceiving, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient meets all of such a grant, and meets the requirements to receive a (FQHC “look alike”), grant funds under Sections 329, 330, 340, or 340A of the Public Health Services (PHS) Act; or that does not currently meet all of the FQHC requirements under the above-mentioned sections PHS Act, but does meet all applicable requirements for Medical Assistance (MA) providers as set forth in Chapter 1101 of the ActMA regulations (including licensure and certification standards under Pennsylvania Law), and receives a temporary waiver from the Secretary of the U.S. Department of Health and Human Services allowing the health center to act as a FQHC. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herselfentity or person, or some other person in a managed care setting. The Fraud can be , committed by many entitiesany entity, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to an MA Managed Care Plan by a Participant or a health care provider (with the written consent of the Participant), or a Participant’s authorized representative to have a CHC-MCO or utilization review entity an MA Managed Care Plan reconsider a decision solely concerning the Medical Necessity and appropriateness medical necessity, appropriateness, health care setting, level of care or effectiveness of a healthcare health care service. A Grievance If the MA Managed Care Plan is unable to resolve the matter, a grievance may be filed regarding a CHC-MCO the decision to 1) deny, in whole or in part, payment for a service/item;that:
Appears in 1 contract
Samples: Community Healthchoices Agreement
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual who is enrolled in both Medicare and MA. Dual Eligible Special Needs Plan – A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is indicated by the eligibility start and end dates in CIS. A blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part. Emergency Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 healthcare service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Expanded Services — Any Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 1396 et seq., but not included in the State’s Medicaid Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness and access to services. External Quality Review Organization - An independent organization that meets the competence and independence requirements set forth in 42 CFR §438.354, and performs EQR as well as other EQR-related activities as set forth in 42 CFR §438.358, or both. 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. Federally Qualified Health Center — 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 — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient drugs determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. 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 CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare service. A Grievance may be filed regarding a CHC-MCO decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
Samples: Community Healthchoices Agreement
Disability Competency. The demonstration that an entity or individual has the capacity to understand the diverse nature of disabilities and the impact that different disabilities can have on a Participant, access to services, and experience of care. 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 Participant’s ability to receive services from a CHC-MCO is terminated. Drug Efficacy Study Implementation (DESI) — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual A Beneficiary who is enrolled in both Medicare and MAMedicare. Dual Eligible Special Needs Plan – (D-SNP) — A Medicare Advantage Plan that primarily or exclusively enrolls individuals who are entitled to enrolled in both Medicare and MedicaidMA. Eligibility Period — A period of time during which an individual is eligible to receive MA benefits. An Eligibility Period is , indicated by the eligibility start and end dates in CIS. A eCIS, and a blank eligibility end date signifies an open-ended Eligibility Period. Eligibility Verification System (EVS) — An automated system available to Providers and other specified organizations for automated verification of MA eligibility, CHC-MCO Enrollment, PCP assignment, TPR, and scope of benefits. Emergency Back-up Plan – The steps to be taken to meet the Participant’s needs during an emergency. Emergency back-up plans address power outages, weather events, travel restrictions, and other events. Federal and state emergency management agencies (FEMA/PEMA) provide guidance on emergency planning. Emergency Medical Condition — A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain 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 or, in 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 Participant Issue — A problem of a CHC-MCO Participant, including problems related to whether an individual is a Participant, 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 Participant 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 Provider, and (b) are needed to evaluate or stabilize an Emergency Medical Condition. Encounter — Any covered healthcare service Covered Service provided to a CHC-MCO Participant, regardless of whether it has an associated Claim. Encounter Data — A record of any Covered Service provided to a Participant and includes Encounters reimbursed through Capitation, FFS, or other methods of compensation payment regardless of whether payment is due or made. Enrollment — The process by which a Participant is enrolled in a CHC-MCO. Enrollment Date — Date that a Beneficiary becomes eligible for CHC. Enterprise Incident Management (EIM) system — Under CHC, EIM is a comprehensive, web-based incident reporting system that provides the capability to record and review incidents for HCBS LTSS program participants. Expanded Services Service — Any A Medically Necessary service provided to a Participant which is covered under Title XIX of the XXXSSA, 00 X.X.X. 42 U.S.C. §0000 § 1396 et seq., but not included in the StateCommonwealth’s Medicaid State Plan. External Quality Review — An annual independent, external review by an EQRO of the quality of services furnished by a CHC-MCO including the evaluation of quality outcomes, timeliness timeliness, and access to services. External Quality Review Organization - (EQRO) — An independent organization that meets the competence and independence requirements set forth in 42 CFR §C.F.R. § 438.354, and performs EQR as well as or other EQR-related activities as set forth in 42 CFR §C.F.R. § 438.358, or both. 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 Diagnosis, treatment, drugs, supplies, and related counseling which are provided to individuals of child-bearing age to enable the individuals voluntarily to determine family size, to space children freely the number and to prevent or reduce the incidence spacing of unplanned pregnanciestheir children. Federally Qualified Health Center (FQHC) — An entity which individual health center site location that is receiving a grant as defined under the Social Xxxxxxxx Xxxreceiving, 00 X.X.X. 0000x(x) or is receiving funding from such a grant under a contract with the recipient meets all of such a grant, and meets the requirements to receive a (FQHC “look alike”), grant funds under Sections 329, 330, 340, or 340A of the Public Health Services (PHS) Act; or that does not currently meet all of the FQHC requirements under the above-mentioned sections PHS Act, but does meet all applicable requirements for Medical Assistance (MA) providers as set forth in Chapter 1101 of the ActMA regulations (including licensure and certification standards under Pennsylvania Law), and receives a temporary waiver from the Secretary of the U.S. Department of Health and Human Services allowing the health center to act as a FQHC. Fee-for-Service (FFS) — Payment to Providers on a per-service basis for healthcare services provided to Beneficiaries. Formulary — A Department-approved list of outpatient Medicaid covered drugs and products not included on the Statewide Preferred Drug List (PDL) and determined by the CHC-MCO’s P&T Committee to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, and cost for the CHC- MCO Participants. MCOs may also refer to this list as the supplemental formulary or supplemental PDL. Fraud — Any type of intentional deception or misrepresentation misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity, him/herselfentity or person, or some other person in a managed care setting. The Fraud can be , committed by many entitiesany entity, including the CHC-MCO, a subcontractor, a Provider, a State employee, or a Participant. Full Dual Eligible - An individual, who is (i) entitled to Medicare Part A, enrolled in or eligible for Medicare Part B, and enrolled in or eligible to enroll in Part D and (ii) full Medicaid eligible. Grievance — A request to have a the CHC-MCO or utilization review entity reconsider a decision solely concerning the Medical Necessity and appropriateness of a healthcare serviceCovered Service. A Grievance may be filed regarding a the CHC-MCO MCO’s decision to 1) deny, in whole or in part, payment for a service/item;
Appears in 1 contract
