Common use of DPW Web Site Clause in Contracts

DPW Web Site. MA Bulletins, RFPs, Program information and other Department communications are available on the DPW Web site at xxxx://xxx.xxx.xxxxx.xx.xx/. SECTION II: DEFINITIONS Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the RFP, Agreement, and the requirements of state or federal regulations) for health care in a managed care setting. The Abuse can be committed by the PH-MCO, subcontractor, Provider, State employee, or a Member, among others. Abuse also includes Member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or Provider. ACCESS Card — An identification card issued by the Department to each MA Recipient. The card must be used by MA-enrolled Health Care Providers to access the Department’s EVS and verify the Recipient’s MA eligibility and specific covered benefits. Actuarially Sound Rates — — Rates that reflect, among other elements:  the populations and benefits to be covered;  the rating groups;  the projected member months for each category of aid;  the historical and projected future medical costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program in the respective county/zone;  program changes to the extent they impact actuarial soundness of the rates;  trend levels for each type of service;  administrative costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program, including assessment costs and profit consideration. Actuarially sound rates are developed using sound methods and assumptions, that are reasonably attainable by the Medicaid Managed Care Organizations in the relevant Agreement year and meet the standards of the Actuarial Standards Board. Adjudicated Claim — A Claim that has been processed to payment or denial. Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association, or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with the PH-MCO or its parent(s), whether such common control be direct or indirect. Without limitation, all officers, or persons, holding five percent (5%) or more of the outstanding ownership interests of PH-MCO or its parent(s), directors or subsidiaries of PH-MCO or parent(s) shall be presumed to be Affiliates for purposes of the RFP and Agreement. For purposes of this definition, "control" means the possession, directly or indirectly, of the power (whether or not exercised) to direct or cause the direction of the management or policies of a person, whether through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be. Alternate Payment Name — The person to whom benefits are issued on behalf of a Recipient. Amended Claim — A Provider request to adjust the payment of a previously Adjudicated Claim. A Provider Appeal is not an Amended Claim. Area Agency on Aging (AAA) — The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities. Behavioral Health Managed Care Organization (BH-MCO) — An entity, operated by county government or licensed by the Commonwealth as a risk- bearing Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which manages the purchase and provision of Behavioral Health Services under an agreement with the Department. Behavioral Health Rehabilitation Services (BHRS) for Children and Adolescents (formerly EPSDT "Wraparound") — Individualized, therapeutic mental health, substance abuse or behavioral interventions/services developed and recommended by an interagency team and prescribed by a physician or licensed psychologist. Behavioral Health (BH) Services — Mental health and/or drug and alcohol services which are provided by the BH-MCO. Business Days — A Business Day includes Monday through Friday except for those days recognized as federal holidays and/or Pennsylvania State holidays.

DPW Web Site. MA Bulletins, RFPs, Program information and other Department communications are available on the DPW Web site at xxxx://xxx.xxx.xxxxx.xx.xx/. SECTION II: DEFINITIONS Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the RFP, Agreement, and the requirements of state or federal regulations) for health care in a managed care setting. The Abuse can be committed by the PH-MCO, subcontractor, Provider, State employee, or a Member, among others. Abuse also includes Member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or Provider. ACCESS Card — An identification card issued by the Department to each MA Recipient. The card must be used by MA-enrolled Health Care Providers to access the Department’s EVS and verify the Recipient’s MA eligibility and specific covered benefits. Actuarially Sound Rates — — Rates that reflect, among other elements:  the populations and benefits to be covered;  the rating groups;  the projected member months for each category of aid;  the historical and projected future medical costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program in the respective county/zone;  program changes to the extent they impact actuarial soundness of the rates;  trend levels for each type of service;  administrative costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program, including assessment costs and profit consideration. Actuarially sound rates are developed using sound methods and assumptions, that are reasonably attainable by the Medicaid Managed Care Organizations in the relevant Agreement year and meet the standards of the Actuarial Standards Board. Adjudicated Claim — A Claim that has been processed to payment or denial. Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association, or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with the PH-MCO or its parent(s), whether such common control be direct or indirect. Without limitation, all officers, or persons, holding five percent (5%) or more of the outstanding ownership interests of PH-MCO or its parent(s), directors or subsidiaries of PH-MCO or parent(s) shall be presumed to be Affiliates for purposes of the RFP and Agreement. For purposes of this definition, "control" means the possession, directly or indirectly, of the power (whether or not exercised) to direct or cause the direction of the management or policies of a person, whether through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be. Alternate Payment Name — The person to whom benefits are issued on behalf of a Recipient. Amended Claim — A Provider request to adjust the payment of a previously Adjudicated Claim. A Provider Appeal is not an Amended Claim. Area Agency on Aging (AAA) — The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities. Behavioral Health Managed Care Organization (BH-MCO) — An entity, operated by county government or licensed by the Commonwealth as a risk- bearing Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which manages the purchase and provision of Behavioral Health Services under an agreement with the Department. Behavioral Health Rehabilitation Services (BHRS) for Children and Adolescents (formerly EPSDT "Wraparound") — Individualized, therapeutic mental health, substance abuse or behavioral interventions/services developed and recommended by an interagency team and prescribed by a physician or licensed psychologist. Behavioral Health (BH) Services — Mental health and/or drug and alcohol services which are provided by the BH-MCO. Business Days — A Business Day includes Monday through Friday except for those days recognized as federal holidays and/or Pennsylvania State holidays.

DPW Web Site. MA Bulletins, RFPs, Program information and other Department communications are available on the DPW Web site at xxxx://xxx.xxx.xxxxx.xx.xx/. SECTION II: DEFINITIONS Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the RFP, Agreement, and the requirements of state or federal regulations) for health care in a managed care setting. The Abuse can be committed by the PH-MCO, subcontractor, Provider, State employee, or a Member, among others. Abuse also includes Member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or Provider. ACCESS Card — An identification card issued by the Department to each MA Recipient. The card must be used by MA-enrolled Health Care Providers to access the Department’s EVS and verify the Recipient’s MA eligibility and specific covered benefits. Actuarially Sound Rates — — Rates that reflect, among other elements:  • the populations and benefits to be covered;  • the rating groups;  • the projected member months for each category of aid;  • the historical and projected future medical costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program in the respective county/zone;  • program changes to the extent they impact actuarial soundness of the rates;  • trend levels for each type of service;  • administrative costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program, including assessment costs and profit consideration. Actuarially sound rates are developed using sound methods and assumptions, that are reasonably attainable by the Medicaid Managed Care Organizations in the relevant Agreement year and meet the standards of the Actuarial Standards Board. Adjudicated Claim — A Claim that has been processed to payment or denial. Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association, or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with the PH-MCO or its parent(s), whether such common control be direct or indirect. Without limitation, all officers, or persons, holding five percent (5%) or more of the outstanding ownership interests of PH-MCO or its parent(s), directors or subsidiaries of PH-MCO or parent(s) shall be presumed to be Affiliates for purposes of the RFP and Agreement. For purposes of this definition, "control" means the possession, directly or indirectly, of the power (whether or not exercised) to direct or cause the direction of the management or policies of a person, whether through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be. Alternate Payment Name — The person to whom benefits are issued on behalf of a Recipient. Amended Claim — A Provider request to adjust the payment of a previously Adjudicated Claim. A Provider Appeal is not an Amended Claim. Area Agency on Aging (AAA) — The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities. Behavioral Health Managed Care Organization (BH-MCO) — An entity, operated by county government or licensed by the Commonwealth as a risk- bearing Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which manages the purchase and provision of Behavioral Health Services under an agreement with the Department. Behavioral Health Rehabilitation Services (BHRS) for Children and Adolescents (formerly EPSDT "Wraparound") — Individualized, therapeutic mental health, substance abuse or behavioral interventions/services developed and recommended by an interagency team and prescribed by a physician or licensed psychologist. Behavioral Health (BH) Services — Mental health and/or drug and alcohol services which are provided by the BH-MCO. Business Days — A Business Day includes Monday through Friday except for those days recognized as federal holidays and/or Pennsylvania State holidays.

DPW Web Site. MA Bulletins, RFPs, Program information and other Department communications are available on the DPW Web site at xxxx://xxx.xxx.xxxxx.xx.xx/. SECTION II: DEFINITIONS Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the RFP, Agreement, and the requirements of state or federal regulations) for health care in a managed care setting. The Abuse can be committed by the PH-MCO, subcontractor, Provider, State employee, or a Member, among others. Abuse also includes Member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or Provider. ACCESS Card — An identification card issued by the Department to each MA Recipient. The card must be used by MA-enrolled Health Care Providers to access the Department’s EVS and verify the Recipient’s MA eligibility and specific covered benefits. Actuarially Sound Rates — — Rates that reflect, among other elements:  • the populations and benefits to be covered;  • the rating groups;  • the projected member months for each category of aid;  • the historical and projected future medical costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program in the respective county/zone;  • program changes to the extent they impact actuarial soundness of the rates;  • trend levels for each type of service;  • administrative costs expected to be incurred by an efficiently and effectively operated Medicaid managed care program, including assessment costs and profit consideration. Actuarially sound rates are developed using sound methods and assumptions, that are reasonably attainable by the Medicaid Managed Care Organizations in the relevant Agreement year and meet the standards of the Actuarial Standards Board. Adjudicated Claim — A Claim that has been processed to payment or denial. Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association, or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with the PH-MCO or its parent(s), whether such common control be direct or indirect. Without limitation, all officers, or persons, holding five percent (5%) or more of the outstanding ownership interests of PH-MCO or its parent(s), directors or subsidiaries of PH-MCO or parent(s) shall be presumed to be Affiliates for purposes of the RFP and Agreement. For purposes of this definition, "control" means the possession, directly or indirectly, of the power (whether or not exercised) to direct or cause the direction of the management or policies of a person, whether through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be. Alternate Payment Name — The person to whom benefits are issued on behalf of a Recipient. Amended Claim — A Provider request to adjust the payment of a previously Adjudicated Claim. A Provider Appeal is not an Amended Claim. Area Agency on Aging (AAA) — The single local agency designated by the Pennsylvania Department of Aging within each planning and service area to administer the delivery of a comprehensive and coordinated plan of social and other services and activities. Behavioral Health Managed Care Organization (BH-MCO) — An entity, operated by county government or licensed by the Commonwealth as a risk- bearing Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which manages the purchase and provision of Behavioral Health Services under an agreement with the Department. Behavioral Health Rehabilitation Services (BHRS) for Children and Adolescents (formerly EPSDT "Wraparound") — Individualized, therapeutic mental health, substance abuse or behavioral interventions/services developed and recommended by an interagency team and prescribed by a physician or licensed psychologist. Behavioral Health (BH) Services — Mental health and/or drug and alcohol services which are provided by the BH-MCO. Business Days — A Business Day includes Monday through Friday except for those days recognized as federal holidays and/or Pennsylvania State holidays.