Common use of Medical Assistance Transportation Program Clause in Contracts

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. Monthly834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity that has a network provider agreement with a PH-MCO or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of the network provider agreement. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and does not have a signed Provider Agreement with a PH-MCO. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Monthly834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity An MA-enrolled Provider that has a network provider agreement with a PH-MCO or a Subcontractor, written Network Provider Agreement and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of participates in the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of ’s Network to serve the network provider agreementPH-MCO’s members. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and that does not have a signed Network Provider Agreement with the PH-MCO and does not participate in the PH-MCO’s network but provides services to a PH-MCOMCO member. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is made to the provider. Pre-payment review is not synonymous with prior authorization. Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily 834 Eligibility Membership File or the Monthly 834 Eligibility Membership File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. Monthly834 Eligibility Monthly Membership File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS CIS that is transmitted to the PH-MCO on a monthly basis. This 834 Monthly File does not include TPL information and is transmitted via the Department’s contractor. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity that has a network provider agreement with a PH-MCO or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of the network provider agreement. Non-participating Provider — A Health Care Provider Provider, either not enrolled in the Pennsylvania Medicaid ProgramMA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to Members. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. CFR §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and does not have a signed Provider Agreement with a PH-MCO. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is made to the provider. Pre-payment review is not synonymous with prior authorization. Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service service, item, procedure, or benefit that is level of care compensable under the MA Program and if it meets any program that is necessary for the proper treatment or management of an illness, injury, or disability is one of the following standardsthat: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. Monthly834 MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Monthly 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity An MA-enrolled Provider that has a network provider agreement with a PH-MCO or a Subcontractor, written Network Provider Agreement and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of participates in the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of ’s Network to serve the network provider agreementPH-MCO’s members. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and that does not have a signed Network Provider Agreement with the PH-MCO and does not participate in the PH-MCO’s network but provides services to a PH-MCOMCO member. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient covered drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is made to the provider. Pre-payment review is not synonymous with prior authorization. Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. Monthly834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity that has a network provider agreement with a PH-MCO or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of the state’s 's contract with a PH-MCO. A network provider is not a Subcontractor by virtue of the network provider agreement. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and does not have a signed Provider Agreement with a PH-MCO. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s 's P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs Prescription Drugs or medical equipment. Medically Necessary — A service service, item, procedure, or benefit that is level of care compensable under the MA Program and if it meets any program that is necessary for the proper treatment or management of an illness, injury, or disability is one of the following standardsthat: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day Day period), including intrapartum, postpartum and gynecological care. Monthly834 MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Monthly 834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity An MA-enrolled Provider that has a network provider agreement with a PH-MCO or a Subcontractor, written Network Provider Agreement and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of participates in the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of ’s Network to serve the network provider agreementPH-MCO’s members. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facilityNursing Facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claimsClaims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and that does not have a signed Network Provider Agreement with the PH-MCO and does not participate in the PH-MCO’s Network but provides services to a PH-MCOMCO Member. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team team-based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network Network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services Emergency Services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment Enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee Enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs Covered Drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees Enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrolleesEnrollees; and (3) Does not have a comprehensive risk contractComprehensive Risk Contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees Enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrolleesEnrollees; and (3) Does not have a comprehensive risk contractComprehensive Risk Contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily 834 Eligibility Membership File or the Monthly 834 Eligibility Membership File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. Monthly834 Eligibility Monthly Membership File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS CIS that is transmitted to the PH-MCO on a monthly basis. This 834 Monthly File does not include TPL information and is transmitted via the Department’s contractor. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity that A MA enrolled Health Care Provider who has a network provider agreement written Provider Agreement with and is credentialed by a PH-MCO or a Subcontractor, and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of who participates in the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of the network provider agreement’s Provider Network to serve Members. Non-participating Provider — A Health Care Provider Provider, either not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between MA Program or not participating in the State and a PIHP PH-MCO’s Network, which provides medical services or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject supplies to the specified limitsMembers. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — —Department phone lines xxxxx designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and does not have a signed Provider Agreement with a PH-PH- MCO. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium Primary Care Practitioner — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees A specific physician, physician group or a CRNP operating under contract with the Departmentscope of his or her licensure, and on the basis of Capitation paymentswho is responsible for supervising, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange forprescribing, and providing primary care services; locating, coordinating and monitoring other medical care and rehabilitative services and maintaining continuity of care on behalf of a Recipient. Primary Care Practitioner Site — The location or office of PCP(s) where Member care is not otherwise responsible delivered. Prior Authorization — A determination made by the PH-MCO to approve or deny payment for a Provider's request to provide a service or course of treatment of a specific duration and scope to a Member prior to the provision Provider's initiation or continuation of any inpatient hospital or institutional services for its enrollees; and the requested service. Prior Authorization Review Panel (3PARP) Does not — A panel of representatives from within the Department who have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has been assigned organizational responsibility for the provision review, approval and denial of any inpatient hospital or institutional services for its enrollees; PH-MCO Prior Authorization policies and (3) Does not have a comprehensive risk contractprocedures. Prepayment Review – Prepayment review is performed after Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the service or item is provided, but prior to payment being issued. Prepayment review may include utilization of which the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the State Medical Practice Act; Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — A Department-approved written agreement between the PH-MCO and (3) Dispensed a Provider to provide medical or professional services to Recipients to fulfill the requirements of this Agreement. Provider Appeal — A request from a Provider for reversal of a determination by the licensed pharmacist PH-MCO, with regard to: Provider Dispute — A written communication to a PH-MCO, made by a Provider, expressing dissatisfaction with a PH-MCO decision that directly impacts the Provider. This does not include decisions concerning medical necessity. Provider-Preventable Condition — A condition that meets the definition of a health care-acquired condition or practitioner on a written prescription that is recorded and maintained other provider-preventable condition as defined in the pharmacist's or practitioner's records42 CFR §447.26(b).

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to and from a MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary — A service or benefit that is compensable under the MA Program and if it meets any one of the following standards: Member — An individual who is enrolled with a PH-MCO under the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of PH Services under the provisions of the HealthChoices Program. Member Record — A record on the Daily 834 Eligibility File or the Monthly 834 Eligibility File that contains information on MA eligibility, managed care coverage, and the category of assistance, which help establish the covered services for which a Recipient is eligible. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period), including intrapartum, postpartum and gynecological care. MMIS Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Monthly834 Eligibility File — An electronic file in a HIPAA compliant 834 format using data from CIS/eCIS that is transmitted to the PH-MCO on a monthly basis. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — any provider, group of providers, or entity An MA-enrolled Provider that has a network provider agreement with a PH-MCO or a Subcontractor, written Network Provider Agreement and receives Medicaid funding directly or indirectly to order, refer or render covered services as a result of participates in the state’s contract with a PH-MCO. A network provider is not a Subcontractor by virtue of ’s Network to serve the network provider agreementPH-MCO’s members. Non-participating Provider — A Health Care Provider not enrolled in the Pennsylvania Medicaid Program. Nonrisk Contract — A contract between the State and a PIHP or PAHP under which the contractor (1) Is not at financial risk for changes in utilization or for costs incurred under the contract that do not exceed the upper payment limits specified in 42 C.F.R. §447.362 and (2) May be reimbursed by the State at the end of the contract period on the basis of the incurred costs, subject to the specified limits. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, enrolled in the MA Program and certified for Medicare participation. The Provider types and specialty codes are as follows: OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by Recipients and their advocates or Providers according to PH-MCO policies and procedures. Ongoing Medication — A medication that has been previously dispensed to the Member for the treatment of an illness that is chronic in nature or for an illness for which the medication is required for a length of time to complete a course of treatment, until the medication is no longer considered necessary by the physician or prescriber, and that has been used by the Member without a gap in treatment. If a current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of the previous dosage. Open-ended — A period of time that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered by the PDA. Other Provider-Preventable Condition — A condition occurring in any health care setting that meets the following criteria: Other Related Conditions — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occu r occur before the age of twenty- two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitations. Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from personal injury claims, liability insurance, first-party automobile medical insurance, and accident indemnity insurance. Out-of-Area Covered Services — Medical services provided to Recipients under one (1) or more of the following circumstances: Out-of-Network Provider — A Health Care Provider who has not been credentialed by and that does not have a signed Network Provider Agreement with the PH-MCO and does not participate in the PH-MCO’s network but provides services to a PH-MCOMCO member. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PH-MCO under the HealthChoices Program comprehensive benefit package. Overpayment — Any payment made to a Network Provider by a PH-MCO or its Subcontractor to which the Network Provider is not entitled to under Title XIX of the Act or any payment to a PH-MCO or its Subcontractor by a State to which the PH-MCO is not entitled to under Title XIX of the Act. Pass-Through Payment — Any amount required by the Department to be added to the contracted payment rates, and considered in calculating the actuarially sound Capitation rate, between the PH-MCO and hospitals, physicians, or nursing facilities that is not for the following purposes: A specific service or benefit provided to a specific enrollee covered under the Agreement; a provider payment methodology permitted under paragraphs (c)(1)(i) through (iii) of 42 C.F.R. §438.6 for services and enrollees covered under the Agreement; a subcapitated payment arrangement for a specific set of services and enrollees covered under the Agreement; GME payments; or FQHC or RHC wrap around payments. Patient Centered Medical Home — This model of care includes key components such as: whole person focus on behavioral health and physical health, comprehensive focus on wellness as well as acute and chronic conditions, increased access to care, improved quality of care, team based approach to care management/coordination, and use of electronic health records (EHR) and health information technology to track and improve care. Pennsylvania Open Systems Network — A peer-to-peer network based on open systems products and protocols that was previously used for the transfer of information between the Department and the MCOs. The Department is currently using IRM Standards. Physical Health Managed Care Organization — A risk bearing entity which has an agreement with the Department to manage the purchase and provision of Physical Health Services under the HealthChoices Program. PH-MCO Coverage Period — A period of time during which an individual is eligible for MA coverage and enrolled with a PH-MCO and which exists on CIS/eCIS. Physical Health Services — Those medical and other related services, provided to Members, for which the PH-MCO has assumed coverage responsibility under this Agreement. Physician Incentive Plan — Any compensation arrangement between an MCO and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to MA Recipients enrolled in the MCO. Post-Stabilization Services — Medically Necessary non-emergency services furnished to a Member after the Member is stabilized following an Emergency Medical Condition. Potential Enrollee — A Medicaid beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll in a given MCO, PIHP, or PAHP, but is not yet an enrollee of a specific MCO, PIHP, or PAHP. Preferred Drug List — A list of Department-approved outpatient covered drugs designated as preferred products because they were determined to have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness and cost for the PH-MCO Members by the PH-MCO’s P&T Committee. Premium — An amount to be paid for an insurance policy. Prepaid Ambulatory Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepaid Inpatient Health Plan — An entity that: (1) Provides services to enrollees under contract with the Department, and on the basis of Capitation payment, or other payment arrangements that do not use State Plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract. Prepayment Review – Prepayment review is performed after the service or item is provided, but prior to payment being issued. Prepayment review may include the examination of an invoice and related documentation to determine eligibility, benefit packages, or medical necessity of a service or item before payment is made to the provider. Pre-payment review is not synonymous with prior authorization. Prescription Drugs — Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are: (1) Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by Federal and State law; (2) Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and (3) Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.