Common use of Prevalent Clause in Contracts

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. 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. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center. Short Procedure Unit — A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Social Determinants of Health (SDOH)— Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes, which can lead to inequities and risks. Special Needs Unit — A special dedicated unit within the PH-MCO and the EAP broker’s organizational structure established to deal with issues related to Members with Special Needs. Start Date — The first date on which the PH-MCO is operationally responsible and financially liable for the provision of Medically Necessary services to Members. Step Therapy — A type of Prior Authorization requirement, sometimes referred to as a fail first requirement, intended as a cost savings that begins drug therapy with the most cost-effective drug therapy, and progresses to other more costly therapies determined to be Medically Necessary. Stop-Loss Protection — Coverage designed to limit the amount of financial loss experienced by a Health Care Provider. Subcapitation — A fixed per capita amount that is paid by the PH-MCO to a Network Provider for each Member identified as being in their capitation group, whether or not the Member received medical services. Subcontract — A contract between the PH-MCO and an individual, business, university, governmental entity, or nonprofit organization to perform part or all of the PH-MCO’s responsibilities under this Agreement. Exempt from this definition are salaried employees, utility agreements and Provider Agreements, which are not considered Subcontracts for the purpose of this Agreement and, unless otherwise specified herein, are not subject to the provisions governing Subcontracts. Subcontractor — An individual or entity that has a contract a PH-MCO that relates directly or indirectly to the performance of the PH-MCO’s obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP. Sustained Improvement — Improvement in performance documented through continued measurement of quality indicators after the performance project, study, or quality initiative is complete.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. 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. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at MCOat a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center. Short Procedure Unit — A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Social Determinants of Health (SDOH)— Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes, which can lead to inequities and risks. Special Needs Unit — A special dedicated unit within the PH-MCO and the EAP broker’s organizational structure established to deal with issues related to Members with Special Needs. Start Date — The first date on which the PH-MCO is operationally responsible and financially liable for the provision of Medically Necessary services to Members. Step Therapy — A type of Prior Authorization requirement, sometimes referred to as a fail first requirement, intended as a cost savings that begins drug therapy with the most cost-effective drug therapy, and progresses to other more costly therapies determined to be Medically Necessary. Stop-Loss Protection — Coverage designed to limit the amount of financial loss experienced by a Health Care Provider. Subcapitation — A fixed per capita amount that is paid by the PH-MCO to a Network Provider for each Member identified as being in their capitation group, whether or not the Member received medical services. Subcontract — A contract between the PH-MCO and an individual, business, university, governmental entity, or nonprofit organization to perform part or all of the PH-MCO’s responsibilities under this Agreement. Exempt from this definition are salaried employees, utility agreements and Provider Agreements, which are not considered Subcontracts for the purpose of this Agreement and, unless otherwise specified herein, are not subject to the provisions governing Subcontracts. Subcontractor — An individual or entity that has a contract a PH-MCO that relates directly or indirectly to the performance of the PH-MCO’s obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP. Sustained Improvement — Improvement in performance documented through continued measurement of quality indicators after the performance project, study, or quality initiative is complete.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees Potential Enrollees that are limited Limited English proficientProficient. (42C.F.R. 438.10(a)) Primary Care — All health care services Health Care Services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or her licensure, and who is responsible for supervising, prescribing, and providing primary care Primary Care services; locating, coordinating and monitoring other medical care and rehabilitative services 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwifeCertified Nurse Midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health servicesBehavioral Health Services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other providerProvider-preventable condition Preventable Condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims Claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees Enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee Enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim Claim that has erroneously been assigned a unique identifier and is removed from the claims Claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is An individual health clinic site engaged primarily in providing typical outpatient clinic services that are typically furnished in outpatient clinics in underserved areas that has been determined by the Secretary of DHHS to meet the requirements of § 1861(aa)(1) of the Social Security Act and 42 Code of Federal Regulations (CFR) Part 491, has filed an agreement with the Secretary in order to provide rural areashealth clinic services under Medicare; and meets all applicable requirements for MA Providers as set forth in 55 Pa. Code Chapter 1101 of the MA regulations (including licensure and certification standards under Pennsylvania Law). School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. 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. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • ● Provider credentialing denial by the PH-MCO; • ● Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • ● Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is An individual health clinic site engaged primarily in providing typical outpatient clinic services that are typically furnished in outpatient clinics in underserved areas that has been determined by the Secretary of the U.S. Department of Health and Human Services to meet the requirements of § 1861(aa)(1) of the Social Security Act and 42 Code of Federal Regulations (CFR) Part 491, has filed an agreement with the Secretary in order to provide rural areashealth clinic services under Medicare; and meets all applicable requirements for MA providers as set forth in Chapter 1101 of the MA regulations (including licensure and certification standards under Pennsylvania Law). School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. 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. Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s 's assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s 's Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s 's current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s 's payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center. Short Procedure Unit — A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Social Determinants of Health (SDOH)— Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes, which can lead to inequities and risks. Special Needs Unit — A special dedicated unit within the PH-MCO and the EAP broker's organizational structure established to deal with issues related to Members with Special Needs. Start Date — The first date on which the PH-MCO is operationally responsible and financially liable for the provision of Medically Necessary services to Members. Step Therapy — A type of Prior Authorization requirement, sometimes referred to as a fail first requirement, intended as a cost savings that begins drug therapy with the most cost-effective drug therapy, and progresses to other more costly therapies determined to be Medically Necessary. Stop-Loss Protection — Coverage designed to limit the amount of financial loss experienced by a Health Care Provider. Subcapitation — A fixed per capita amount that is paid by the PH-MCO to a Network Provider for each Member identified as being in their capitation group, whether or not the Member received medical services. Subcontract — A contract between the PH-MCO and an individual, business, university, governmental entity, or nonprofit organization to perform part or all of the PH-MCO's responsibilities under this Agreement. Exempt from this definition are salaried employees, utility agreements and Provider Agreements, which are not considered Subcontracts for the purpose of this Agreement and, unless otherwise specified herein, are not subject to the provisions governing Subcontracts. Subcontractor — An individual or entity that has a contract a PH-MCO that relates directly or indirectly to the performance of the PH-MCO's obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP. Sustained Improvement — Improvement in performance documented through continued measurement of quality indicators after the performance project, study, or quality initiative is complete.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 42CFR 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — An Any individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: • Provider credentialing denial by the PH-MCO; • Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and • Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. CFR §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.

Prevalent. A non-English language determined to be spoken by a significant number or percentage of potential enrollees that are limited English proficient. (42C.F.R. 42CFR 438.10(a)) Primary Care — All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them. Primary Care Practitioner — A specific physician, physician group or a CRNP operating under the scope of his or 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 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 PH-MCO Prior Authorization policies and procedures. Prior Authorized Services — In-Plan Services, determined to be Medically Necessary, the utilization of which the PH-MCO manages in accordance with Department-approved Prior Authorization policies and procedures. PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base MPI Provider Number and a 4-digit service location. Provider — An Any individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services, including a physician, podiatrist, optometrist, psychologist, physical therapist, CRNP, RN, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist, and an individual accredited or certified to provide behavioral health services. Provider Agreement — A 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 determination by the PH-MCO, with regard to: •  Provider credentialing denial by the PH-MCO; •  Claims denied by the PH-MCO for Providers participating in the PH-MCO’s Network. This includes payment denied for services already rendered by the Provider to the Member; and •  Provider Agreement termination by the PH-MCO. 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 other provider-preventable condition as defined in 42 C.F.R. CFR §447.26(b). Provider Reimbursement and Operations Management Information System electronic (PROMISe™) — The Department’s current MMIS claims processing and management system that supports the FFS and MA Managed Care delivery programs. Quality Management — An ongoing, objective and systematic process of monitoring, evaluating and improving the quality, appropriateness and effectiveness of care. Rate Cell — A set of mutually exclusive categories of enrollees that is defined by one or more characteristics for the purpose of determining the Capitation rate and making a Capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the Agreement. Rating Period — A period of twelve (12) months selected by the Department for which the actuarially sound Capitation rates are developed and documented in the rate certification, submitted to CMS as required by 42 C.F.R. §438.7(a). Recipient — A person eligible to receive Physical or Behavioral Health Services under the MA Program of the Commonwealth of Pennsylvania. Recipient Month — One Member covered by the HealthChoices Program for one (1) calendar month. Rehabilitative Services — This includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of physical or mental disability and restoration of a beneficiary to his best possible functional level. Rejected Claim — A non-claim that has erroneously been assigned a unique identifier and is removed from the claims processing system prior to adjudication. Related Party — An entity that is an Affiliate of the PH-MCO or subcontracting PH-MCO and (1) performs some of the PH-MCO or subcontracting PH-MCO's management functions under contract or delegation; or (2) furnishes services to Members under a written agreement; or (3) leases real property or sells materials to the PH-MCO or subcontracting PH-MCO at a cost of more than $2,500.00 during any year of a HealthChoices Agreement with the Department. Residential Treatment Facility — A facility licensed by the Department that provides twenty-four (24) hour out-of-home care, supervision and Medically Necessary mental health services for individuals under twenty-one (21) years of age with a diagnosed mental illness or severe emotional disorder. Retrospective Review — A review conducted by the PH-MCO, DHS, or DHS vendor or designee to determine whether services were delivered as prescribed and consistent with the PH-MCO’s payment policies and procedures in accordance with MA regulations and section V.0.4.p of the Agreement. Revenue [for the purposes of the Equity requirement calculation] — The total gross Direct Business Premiums, for all Pennsylvania lines of business, reported in Schedule T, “Premiums and other Considerations,” of the PID report. Risk Based Capital — The Total Adjusted Capital figure in Column One from the page titled Five Year Historical Data in the Annual Statement for the most recent year filed with PID, divided by the Authorized Control Level Risk-based Capital figure. Risk Contract — A contract between the State, an MCO, PIHP, or PAHP under which the contractor: (1) Assumes risk for the cost of the services covered under the contract, and (2) Incurs loss if the cost of furnishing the services exceeds the payments under the contract. Risk Corridor — A risk sharing mechanism in which the Department and PH- MCOs may share in profits and losses under the Agreement outside of a predetermined threshold amount. Routine Care — Care for conditions that generally do not need immediate attention and minor episodic illnesses that are not deemed urgent. This care may lead to prevention or early detection and treatment of conditions. Examples of preventive and routine care include immunizations, screenings and physical exams. Rural Health Clinics (RHCs) - a facility that is engaged primarily in providing services that are typically furnished in outpatient clinics in underserved rural areas. School-Based Health Center — A health care site located on school building premises which provides, at a minimum, on-site, age-appropriate primary and preventive health services with parental consent, to children in need of primary health care and which participates in the MA Program and adheres to EPSDT standards and periodicity schedule. School-Based Health Services — An array of Medically Necessary health services performed by licensed professionals that may include, but are not limited to, immunization, well child care and screening examinations in a School-Based Health Center.