Common use of Medical Assistance Transportation Program Clause in Contracts

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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 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 Department of Aging. Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, the utilization of which the PH- MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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.

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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. Mental Retardation — An impairment in intellectual functioning which is lifelong and originates during the developmental period (birth to twenty-two (22) years). It results in substantial limitations in three or more of the following areas: learning, self-direction; self care; expressive and/or receptive language; mobility; capacity for independent living; and economic self-sufficiency. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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 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 Department of Aging. Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, the utilization of which the PH- MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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.

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/to or from a any MA reimbursable service for the purpose of receiving treatment, medical evaluation, or purchasing prescription drugs or medical equipment. Medically Necessary (also referred to as Medical Necessity) — A service or benefit Covered Service is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards: Member MIPPA Agreement – An agreement required under the MIPPA of 2008 between a D-SNP and a State Medicaid Agency which documents entities’ roles and responsibilities with regard to Dual Eligibles and describes the D- SNP’s responsibility to integrate and coordinate Medicare and Medicaid benefits. Monthly Participant File — An individual who electronic file in a HIPAA compliant 834 format using data from CIS that is enrolled with a PHtransmitted to the CHC-MCO under on a monthly basis via the HealthChoices Program and for whom the PH-MCO has agreed to arrange the provision of Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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). This includes intrapartum, postpartum and gynecological careDepartment’s MIS contractor. Network — All contracted or employed Providers in with the PHCHC-MCO who are providing covered services Covered Services to MembersParticipants. Network Provider — A Medical Assistance MA enrolled Health Care Healthcare Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PHCHC-MCO and who participates in the PHCHC-MCO’s Provider Network to serve HealthChoices MembersCHC Participants. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A providerProvider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PHCHC-MCO’s Network, which provides medical services or supplies to PH-MCO Members. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH, DOH and enrolled in the MA Program and certified for Medicare participationProgram. The Provider types and specialty codes are as follows: OMAP Hotlines — The PH-MCO will cooperate with Nursing Facility Clinically Eligible – Having clinical needs that require the functions level of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providerscare provided in a Nursing Facility. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and Nursing Facility Ineligible – Having clinical needs that do not impose additional obligations on require the PH-MCOlevel of care provided in a Nursing Facility. Ongoing Medication — A medication that has been previously dispensed to the Member Participant 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 Open-ended — A period of time treatment, until the medication is no longer considered necessary by the physician/prescriber, and that has a start date but no definitive end date. OPTIONS — The long-term care pre-admission assessment program administered been used by the Department of AgingParticipant without a gap in treatment. Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which occur before the age of twenty- twenty-two (22), is likely to continue indefinitely and results in three (3) or more substantial functional limitationslimitations in the following areas: self-care, receptive and expressive language, learning, mobility, self-direction and capacity for independent living. 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 insuranceindemnityinsurance. Out-of-Area Covered Services — Medical services —Covered Services provided to Recipients a Participant 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 HealthChoices PHthe CHC-MCO. Out-of-Plan Services — Services which are non-plan, non-capitated and are not the responsibility of the PHCHC-MCO under the HealthChoices CHC Program comprehensive benefit Covered Services package. Pennsylvania Open Systems Network (POSNet) Participant — A peer-to-peer network based on open systems products and protocols that was previously used for An eligible individual who is enrolled with the transfer of information between the Department and the MCOs. The Department is currently using Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PHCHC-MCO) — 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. Physical Health (PH) 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 Medicaid 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. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, the utilization of which the PH- MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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.

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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. Mental Retardation — An impairment in intellectual functioning which is lifelong and originates during the developmental period (birth to twenty-two (22) years). It results in substantial limitations in three or more of the following areas: learning, self-direction; self care; expressive and/or receptive language; mobility; capacity for independent living; and economic self-sufficiency. Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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/prescriber, and that has been used by the Member without a gap in treatment. If the current prescription is for a higher dosage than previously prescribed, the prescription is for an Ongoing Medication at least to the extent of 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 Department of Aging. Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Provider's initiation or continuation of the requested service. Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, the utilization of which the PH- MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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.

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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. Mental Retardation — An impairment in intellectual functioning which is lifelong and originates during the developmental period (birth to twenty-two (22) years). It results in substantial limitations in three or more of the following areas: Midwifery Practice — Management of the care of essentially healthy women and their healthy neonates (initial twenty-eight [28] day period). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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/prescriber, and that has been used by the Member without a gap in treatment. If the 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. When payment is authorized due to the obligation to cover pre-existing services while a Grievance or DPW Fair Hearing is pending, a request to refill that prescription, made after the Grievance or DPW Fair Hearing has been finally concluded in favor of the MCO, is not an Ongoing Medication. 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 Department of Aging. Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Provider's initiation or continuation of the requested service. Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, the utilization of which the PH- MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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.

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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/prescriber, and that has been used by the Member without a gap in treatment. If the 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. When payment is authorized due to the obligation to cover pre-existing services while a Grievance or DHS Fair Hearing is pending, a request to refill that prescription, made after the Grievance or DHS Fair Hearing has been finally concluded in favor of the MCO, is not an Ongoing Medication. 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 Department of Aging. Other Provider-Preventable Condition (OPPC)— A condition occurring in any health care setting that meets the following criteria: Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. 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 Pharmacy and Therapeutics (P&T) Committee. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Provider's initiation or continuation of the requested service. Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH- PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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 (PPC) — A condition that meets the definition of a health care-acquired condition (HCAC) or other provider-preventable condition (PPC) as defined in 42 CFR 447.26(b).

Medical Assistance Transportation Program. (MATP) — A non-emergency medical transportation service provided to eligible persons who need to make trips to/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 is Medically Necessary if it 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 Physical Health Services under the provisions of the HealthChoices Program. Member Record — A record contained on the Daily Membership File or the Monthly 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). This includes intrapartum, postpartum and gynecological care. Network — All contracted or employed Providers in the PH-MCO who are providing covered services to Members. Network Provider — A Medical Assistance enrolled Health Care Provider who has a written Provider Agreement with and is credentialed by a HealthChoices PH-MCO and who participates in the PH-MCO’s Provider Network to serve HealthChoices Members. Net Worth (Equity) — The residual interest in the assets of an entity that remains after deducting its liabilities. Non-participating Provider — A provider, whether a person, firm, corporation or other entity, either not enrolled in the Pennsylvania MA Program or not participating in the PH-MCO’s Network, which provides medical services or supplies to PH-MCO Members. 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 — The PH-MCO will cooperate with the functions of OMAP’s Hotlines, which are designed to address clinically-related systems issues encountered by Recipients and their advocates or Providers. The OMAP Hotlines facilitate resolution according to PH-MCO policies and procedures and do not impose additional obligations on the PH-MCO. 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/prescriber, and that has been used by the Member without a gap in treatment. If the 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. When payment is authorized due to the obligation to cover pre-existing services while a Grievance or DHS Fair Hearing is pending, a request to refill that prescription, made after the Grievance or DHS Fair Hearing has been finally concluded in favor of the MCO, is not an Ongoing Medication. 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 Department of Aging. Other Provider-Preventable Condition (OPPC)— A condition occurring in any health care setting that meets the following criteria: Other Related Conditions (ORC) — A physical disability such as cerebral palsy, epilepsy, xxxxx bifida or similar conditions which 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 HealthChoices 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. Pennsylvania Open Systems Network (POSNet) — 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 Information Resource Management (IRM) Standards. Physical Health Managed Care Organization (PH-MCO) — 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. Physical Health (PH) 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 Medicaid 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. 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 Pharmacy and Therapeutics (P&T) Committee. Preferred Provider Organization (PPO) — A Commonwealth licensed person, partnership, association or corporation which establishes, operates, maintains or underwrites in whole or in part a preferred provider arrangement as defined in 31 Pa. Code 152.2. Primary Care Case Management (PCCM) — A program under which the Primary Care Practitioners agree to be responsible for the provision and/or coordination of medical services to Recipients under their care. Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, 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 (PCP) Site — The location or office of PCP(s) where Member care is 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 Provider's initiation or continuation of the requested service. Prior Authorization Review Panel (PARP) — A panel of representatives from within the Department who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH- PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — A person, firm or corporation, enrolled in the Pennsylvania MA Program, which provides services or supplies to Recipients. Provider Agreement — Any Department-approved written agreement between the PH-MCO and 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 denial by the PH- MCO, with regard to the three (3) major types of issues that are to be addressed in a Provider Appeal system as outlined in this Agreement at Section V.K, Provider Dispute Resolution System. The three (3) types of Provider Appeals issues are: 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 (PPC) — A condition that meets the definition of a health care-acquired condition (HCAC) or other provider-preventable condition (PPC) as defined in 42 CFR 447.26(b).