Common Terms
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A
ACCESS Card - Medical Assistance Identification card.
The PA ACCESS card is issued to individuals for MA benefits. The card is one
of the methods that may be used by medical providers to verify MA consumer eligibility
for medical services through the Eligibility Verification System (EVS)
Acute Care - Short-term care for a person with a single
episode of short-term illness or with an exacerbation of a chronic condition.
Adjudicated Claim - A claim that has been processed
to payment or denial Administrative Costs - Costs not linked directly to the
provision of medical care. Includes marketing, claims processing, bill and medical
record keeping among others.
Alternate Payment Name - The person to whom benefits
are issued on behalf of an MA consumer
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B
Behavioral Health Care Firm - Specialized (for profit) managed care organizations,
focusing on mental health and substance abuse benefits, which they term "behavioral
health." These firms offer employers and public agencies a managed mental health
and substance abuse benefit.
Behavioral Health Rehabilitation Services for Children and Adolescents
- (formerly EPSDT Wraparound) Individualized, therapeutic mental health, substance
abuse or behavioral interventions/services developed and recommended by an interagency
team and prescribed by a physician or licensed psychologist.
Behavioral Health Services - Mental health and/or drug and alcohol services,
which are provided by the BH-MCO.
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C
Capitation - A fixed amount of money paid per person
for covered services for a specific time; usually expressed in units of per
member per month (pmpm).
Carve-out- A separate contract or sub contract for a
certain population such as those with mental health or substance abuse problems.
Case Management Services - Services which will assist
individuals in gaining access to necessary medical, social, educational and
other services
Case Payment Name - The person in whose name benefits
are issued
Client Information System - The Department's database
of MA consumers. The database contains demographic and eligibility information
for all MA consumers
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D
Denial of Services - Any determination made by the Contractor in response
to a provider's request for approval to provide MA covered services of a specific
duration and scope which; disapproves the request completely; approves provision
of the requested service(s), but for a lesser scope or duration than requested
by the provider; or disapproves provision of the requested service(s). An approval
of a requested service, which includes a requirement for a concurrent review
by the Contractor during the authorized period does not constitute a denial.
Denied Claim - An adjudicated claim that does not result in a payment
obligation to a provider
Deprivation Qualifying Code - The code specifying the condition which
determines an MA consumer to be eligible in nonfinancial criteria.
DPW Fair Hearing - For the purpose of the RFP and Agreement, a hearing
conducted by the Department of Public Welfare, Bureau of Hearings and Appeals
or its subcontractor, in response to grievance to the Department by a PH-MCO
member.
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E
Eligibility Period - A period of timer during which a consumer is eligible
to receive MA benefits. An eligibility period is indicated by the eligibility
start and end dates on CIS. A blank eligibility end date signifies an open-ended
eligibility period.
Eligibility Verification System (EVS) - An automated system available
to MA providers and other specified organizations for on-line verification of
MA eligibility, prepaid capitation, PH-MCO or BH-MCO enrollment, third party
resources, and the Benefit Package under the MA Fee-for-Service (FFS) Programs.
Emergency Member Issue - A problem of a PH-MCO member (including problems
related to whether an individual is a member), the resolution of which should
occur immediately or before the beginning of the next business day in order
to prevent a denial or medically significant delay in care to the member that
could precipitate a medical emergency condition or need for urgent care.
Emergency Services - Covered inpatient and outpatient services that:
(a) are furnished by a provider that is qualified to furnish such service under
Title IX and (b) are needed to evaluate or stabilize an emergency medical condition.
Enrollee - person eligible for service from a managed care plan.
Expanded Services - An expanded service is any medically necessary service,
eligible under Title XIX of the Social Security Act, not included in the State
Plan, which is being provided to an individual, under age 21, who is enrolled
in the Medical Assistance (MA) Program.
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F
Federally Qualified Health Center (FQHC) - An entity
which is receiving a grant under the Public Health Services Act (42 U.S.C. Section
329, 330 or 340) or is receiving funding from such a grant under a contract
with the recipient of such a grant, and meets the requirements to receive a
grant under the above-mentioned sections of the Act.
Fee for Service - payment of specific amounts for specific
services rendered on a service unit basis.
Formulary - An exclusive list of drug products for which
the Contractor will provide coverage to its members, as approved by the Department.
Fraud - An intentional deception or misrepresentation
or concealment of the facts made by a person with the knowledge that the deception
could result in some unauthorized benefit to himself/herself or another person.
It includes any act that constitutes fraud under applicable federal or state
law.
Freedom of Choice - the ability of consumers to select
their own doctors. In Medicaid, the federal requirement that individuals be
able to choose their health care providers.
Full Risk Plans - general health maintenance organizations,
these are fully capitated plans that, for a fixed monthly fee per enrolled,
assume the financial risk of providing all medically necessary services.
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G
Gatekeeper - primary care physician responsible for coordinating and
managing health care needs of members. Generally in order for speciality services,
such as mental health and hospital care to be covered, the gatekeeper must first
approve the referral.
Grievance - Request by an enrollee or a health care provider, with written
consent of the enrollee, to have the Managed Care Plan or Utilization Review
Entity reconsider a decision solely concerning medical necessity and appropriateness
of health care service. If the Managed Care Plan is unable to resolve the matter,
a grievance may be filed regarding a decision that: 1) disapproves full or partial
payment for requested health care services; 2) approves a provision of a requested
health care service for a lesser scope or duration than requested; or 3) disapproves
payment for provisions of a requested health care service but approves payment
for provision of an alternative health care service. The term does not included
a complaint.
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H
Health Care Financing Agency - the federal agency that
oversees the Medical Assistance program.
Health Care Professional - Physician or other health
care provider/practitioner if coverage for the professional's services, provided
for under the professional scope of practice, and included under the contract
for the services of the professional. This term includes, but is not limited
to: podiatrist, optometrist, chiropractor, psychologist, dentist, physician
assistant, physical or occupational therapist and therapy assist, speech-language
pathologist, audiologist, registered or licensed practical nurse (including
nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist
and certified nurse-midwife), licensed certified social worker, registered respiratory
therapist and certified respiratory therapy technician.
Health Maintenance Organization (HMO) - as defined in
the Health Maintenance Act of 1973. A legal entity or organized system of health
care that provides directly (or arranges for) a comprehensive range of basic
and supplemental health care services to a voluntarily enrolled population in
a geographic area on the primarily prepaid and fixed period basic.
HealthChoices Disenrollment - Action taken by the Department
to remove a member's name from the monthly Enrollment Report follow the Department's
receipt of a determination that the member is no longer eligible for enrollment
in HealthChoices.
HealthChoices Program - The name of Pennsylvania's 1915(b)-waiver
program to provide mandatory managed health care to MA consumers.
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I
Indemnity Health Insurance - plan that reimburses physicians and other
providers for health services furnished to enrollees.
Independent Enrollment Assistance Program (IEAP) - The program responsible
to assist MA consumers in enrolling the HealthChoices Program including the
selection of the PH-MCO and Primary Care Practitioner(PCP) as well as how to
obtain information regarding HealthChoices physical and behavioral health services
and service providers.
Inquiry - Any member's request for administrative service, information
or to express an opinion. Whenever specific corrective action is requested by
the member, or determined to be necessary by the Contractor, it should be classified
as a complaint.
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J
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K
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L
Lock-In - If a consumer identified as abusing services provided under
the MA program, they are restricted (locked-in) to a specific provider(s) to
obtain all of their services to ensure they receive comprehensiveness of care.
Loss Ratio - ratio of managed care entity's actual incurred expenses
to total premiums.
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M
MA Consumer - A person enrolled to receive services
under the Medical Assistance (MA) Program in the Commonwealth of Pennsylvania.
Medicaid Waiver - permits a state to develop a Medicaid
program that does not comply with all requirements of federal law, although
certain safeguards must be met.
Medical Assistance Transportation Program (MATP) - Is
a non-emergency medical transportation service provided to eligible persons
who need to make trips to/from a medical assistance reimbursable service for
the purpose of receiving treatment, medical evaluation, or purchasing prescription
drugs or medical equipment.
Medically Necessary - a determination made by a third
party payer or a review organization regarding whether a given medical intervention
was, in fact, necessary for a particular patient.
Member - An individual who is enrolled with a PH-MCO
under the HC-SE Program and for whom the PH-MCO is responsible to provide physical
health services under the provisions of the HealthChoices Physical Health Program.
Michael Dallas Model Waiver (MDMW) - A program operating
under a federal waiver that provides essential home care services, beyond the
scope of traditional MA, to technology-dependent individuals under the age of
twenty-one (21). The goal is to maintain the children in the community, thus
avoiding an institutional setting.
Monthly Membership File - An electronic file generated
by the Department using CIS that is transmitted to the Primary Contractor. The
Monthly Membership File lists retroactive, current and prospective PH-MCO members,
specifying for each PH-MCO Member the corresponding eligibility period, PH-MCO
coverage and BH-MCO coverage. Consumers no t included on this file with an indication
of prospective coverage will not be the responsibility of the PH-MCO unless
a subsequent Daily Membership file indicated otherwise. Those with an indication
of future month coverage will not be the responsibility of the PH-MCO if a Daily
Membership File received by the PH-MCO prior to the beginning of the future
month indicates otherwise.
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N
Network - Means all contracted or employed providers in the Health Plan
who are providing covered services to members.
Network Provider - A health care professional who has a written provider
agreement with a HC-SE PH-MCO and is included and identified as being in the
PH-MCO's provider network to serve HealthChoices members.
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O
OPTIONS - The long-term care pre-admission assessment program operated
by the Department of Aging under contract with the Department of Public Welfare.
Outcomes Measure - a tool to assess the impact of health services in
terms of improved quality and/or longevity of life and functioning.
Out-of-Area Covered Services - Medical services provided to MA consumers
that meet one (1) or more of the following criteria:
- An emergency medical condition that occurs while outside the project area;
- The health of the MA consumer would be endangered if the MA consumer returned
to the project area for needed services;
- The provider is located outside the project area but is nonetheless a subcontractor
regularly providing medical services to MA consumers at the request of the
PH-MCO; or
- The needed medical services are not available in the project area.
Out-of-Network Provider - A health care profession who has not been
credentialed by and does not have a signed provider agreement with a HC-SE PH-MCO.
Out-of-Plan Services - Services which are non-plan, non-capitated and
are not the responsibility of the Contractor under the HC-SE Program comprehensive
benefit package. These must be coordinated with in-plan service delivery.
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P
Performance Measure - a measure that describes the health
care being provided. Current performance measures indicate whether a health
plan or provider has appropriately provided certain services expected to lead
to desirable outcomes. Performance measures do not necessarily address client
outcomes directly.
POSNet - The Department's Pennsylvania Open Systems
network(POSNet) which is peer-to-peer network based on open systems products
and protocols.
Preferred Provider Organization (PPO) - A Commonwealth
licensed person, partnership, association or corporation which establishes,
operates, maintains or underwrites in whole or in part a preferred provider
arrangement as defined in Pa. Regulations, Title 31, Part VIII, Chapter 152,
Subsection 152.2.
Primary Care - professional and related services administered
by an internist, family practitioner or pediatrician in an ambulatory setting.
Primary Care Case Management (PCCM) - A Freedom of Choice
waiver program, under the authority of Section 1915(b) of the Social Security
Act. States contract directly with primary care providers who agree to be responsible
for the provision and/or coordination of medical services to MA consumers under
their care. Currently, most PCCM programs pay the primary care provider a monthly
case management fee in addition to receiving fee-for-service payment.
Provider - A person, firm or corporation, enrolled in
the Pennsylvania MA Program, which provides services or supplies to MA consumers.
A minority provider refers to a provider who is African-American, Hispanic,
Asian or other ethnic minority.
Provider Agreement - Any Department-approved written
agreement between the Contractor and a provider to provide medical or professional
services to MA consumer to fulfill the requirements of the contract.
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 decision concerning medical necessity.
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Q
Quality Management - An ongoing, objective and systematic process of
monitoring, evaluating and improving the quality, appropriateness and effectiveness
of care.
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R
Recipient - A person eligible to receive medical and/or behavioral health
services under the MA program of the Commonwealth of Pennsylvania.
Rejected Claim - A non-HealthChoices claim or a claim that has erroneously
been assigned a unique identifier and is removed from the claims processing
system prior to adjudication.
Report Card - a published report for consumers on the premium costs
for a plan and overall quality of a health plan or provider. Report cards generally
include measures of the plan's delivery of appropriate services, patient outcomes,
patient satisfaction and cost structure.
Residential Treatment Facility (RTF) - A facility licensed by the Department
of Public Welfare 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 Contractor to determine
whether services were delivered as prescribed and consistent with the Contractor's
payment policies and procedures.
Risk - possibility that revenues of the insurer will not be sufficient
to cover expenditures incurred in the delivery of contractual services. A managed
care provider is at risk if actual expenses exceed the payment amount.
Risk Adjustment - the adjustment of premiums or outcome measures to
compensate health plans for the risks associated with individuals who are more
likely to require costly treatment. Risk adjustment takes into account the health
status and risk profile of patients (for example, severity of illness, comorbidity,
consumption of cigarettes and alcohol).
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S
Spend-down - A process of establishing eligibility for
MA by allowing consumers to spend their excess net income on certain incurred
or paid medical expenses. Eligibility may need to be redetermined monthly.
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T
Targeted Case Management (TCM) Program - A case management program for
MA consumers who are diagnosed with AIDS or symptomatic HIV. Qualified case
managers ensure timely access to comprehensive medical and social services.
Third Party Liability (TPL) - The financial responsibility for all or
part of a member's healthcare expenses of an individual entity or program (e.g.,
Medicare) other than the Contractor.
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U
Utilization Review (UR) - evaluation of the necessity,
appropriateness and efficiency of the use of health services, procedures and
facilities. This includes review of appropriateness of admissions, services
ordered and provided, length of stay and discharge practices on a concurrent
and retrospective basis.
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V
Voided Member Record - A member Record used by the Department to advise
the Primary Contractor that a certain related Member Record previously submitted
by the Department to the Primary Contractor should be voided. A Voided Member
Record can be recognized by its illogical sequence of PH-MCO membership start
and end dates with the end date preceding the start date.
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W
Waiver - A process by which a state may obtain an approval from HCFA
for an exception to a federal Medicaid requirement(s).
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