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 or from any MA 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 Covered Service is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards:  The Covered Service will, or is reasonably expected to, prevent the onset of an illness, condition or disability.  The Covered Service will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.  The Covered Service will assist the Participant to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Participant and those functional capacities that are appropriate for Participants of the sameage. 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 electronic file in a HIPAA compliant 834 format using data from CIS that is transmitted to the CHC-MCO on a monthly basis via the Department’s MIS contractor. Network — All contracted or employed Providers with the CHC-MCO who are providing Covered Services to Participants. Network Provider — A MA enrolled Healthcare Provider who has a written Provider Agreement with and is credentialed by a CHC-MCO and who participates in the CHC-MCO’s Network to serve CHC Participants. 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 CHC-MCO’s Network. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH and enrolled in the MA Program. Nursing Facility Clinically Eligible – Having clinical needs that require the level of care provided in a Nursing Facility. Nursing Facility Ineligible – Having clinical needs that do not require the level of care provided in a Nursing Facility. Ongoing Medication — A medication that has been previously dispensed to the 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 treatment, until the medication is no longer considered necessary by the physician/prescriber, and that has been used by the Participant without a gap in treatment. Other Related Conditions — 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 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 indemnityinsurance. Out-of-Area Covered Services —Covered Services provided to a Participant under one (1) or more of the following circumstances:  An Emergency Medical Condition that occurs while outside the CHC zone.  The health of the Participant would be endangered if the Participant returned to the CHC zone for needed services.  The Participant is attending a college or university in a state other than Pennsylvania or a zone other than his or her zone of residence or who is travelling outside of the CHC zone but remains a resident of the Commonwealth and the CHC zone and requires Covered Services, as identified in his or her PCSP or otherwise.  The Provider is located outside the CHC zone, but regularly provides Covered Services to Participants at the request of the CHC-MCO.  The needed Covered Services are not available in the CHC zone. Out-of-Network Provider — A Provider who has not been credentialed by and does not have a signed Provider Agreement with the CHC-MCO. Out-of-Plan Services — Services which are non-capitated and are not the responsibility of the CHC-MCO under the CHC Program Covered Services package. Participant — An eligible individual who is enrolled with the CHC-MCO.

Medical Assistance Transportation Program. A non-emergency medical transportation service provided to eligible persons who need to make trips to or from any MA 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 Covered Service is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards:  • The Covered Service will, or is reasonably expected to, prevent the onset of an illness, condition or disability.  • The Covered Service will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.  • The Covered Service will assist the Participant to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Participant and those functional capacities that are appropriate for Participants of the sameage. 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 electronic file in a HIPAA compliant 834 format using data from CIS that is transmitted to the CHC-MCO on a monthly basis via the Department’s MIS contractor. Network — All contracted or employed Providers with the CHC-MCO who are providing Covered Services to Participants. Network Provider — A MA enrolled Healthcare Provider who has a written Provider Agreement with and is credentialed by a CHC-MCO and who participates in the CHC-MCO’s Network to serve CHC Participants. 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 CHC-MCO’s Network. Nursing Facility — A general, county or hospital-based nursing facility, which is licensed by the DOH and enrolled in the MA Program. Nursing Facility Clinically Eligible – Having clinical needs that require the level of care provided in a Nursing Facility. Nursing Facility Ineligible – Having clinical needs that do not require the level of care provided in a Nursing Facility. Ongoing Medication — A medication that has been previously dispensed to the 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 treatment, until the medication is no longer considered necessary by the physician/prescriber, and that has been used by the Participant without a gap in treatment. Other Related Conditions — 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 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 indemnityinsurance. Out-of-Area Covered Services —Covered Services provided to a Participant under one (1) or more of the following circumstances:  • An Emergency Medical Condition that occurs while outside the CHC zone.  • The health of the Participant would be endangered if the Participant returned to the CHC zone for needed services.  • The Participant is attending a college or university in a state other than Pennsylvania or a zone other than his or her zone of residence or who is travelling outside of the CHC zone but remains a resident of the Commonwealth and the CHC zone and requires Covered Services, as identified in his or her PCSP or otherwise.  • The Provider is located outside the CHC zone, but regularly provides Covered Services to Participants at the request of the CHC-MCO.  • The needed Covered Services are not available in the CHC zone. Out-of-Network Provider — A Provider who has not been credentialed by and does not have a signed Provider Agreement with the CHC-MCO. Out-of-Plan Services — Services which are non-capitated and are not the responsibility of the CHC-MCO under the CHC Program Covered Services package. Participant — An eligible individual who is enrolled with the CHC-MCO.