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28 Pa. Code § 9.602. Definitions.

§ 9.602. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Act—The Insurance Company Law of 1921 (40 P. S. § §  361—991.2361).

   Act 68—The act of June 17, 1998 (P. L. 464, No. 68) (40 P. S. § §  991.2001—991.2361) which added Articles XX and XXI of the act.

   Active clinical practice—The practice of clinical medicine by a health care provider for an average of not less than 20 hours per week.

   Ancillary service plan

     (i)   An individual or group health insurance plan, subscriber contract or certificate, that provides exclusive coverage for dental services or vision services.

     (ii)   The term also includes Medicare Supplement Policies subject to section 1882 of the Social Security Act (42 U.S.C.A. §  1395ss) and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.

   Ancillary services—A health care service that is not directly available to enrollees but is provided as a consequence of another covered health care service, such as radiology, pathology, laboratory and anesthesiology.

   Article XXI—Sections 2101—2193 of the act (40 P. S. § §  991.2101—991.2193) relating to health care accountability and protection.

   Basic health services or basic health care services—The health care services in §  9.651 (relating to HMO provision and coverage of basic health care services to enrollees).

   CRE—Certified utilization review entity—An entity certified under this chapter to perform UR on behalf of a plan.

   Certificate of authority—The document issued jointly by the Secretary and the Commissioner that permits a corporation to establish, maintain and operate an HMO.

   Commissioner—The Insurance Commissioner of the Commonwealth.


     (i)   A dispute or objection by an enrollee regarding a participating health care provider, or the coverage (including contract exclusions and non-covered benefits), operations or management policies of a managed care plan, that has not been resolved by the managed care plan and has been filed with the plan or the Department or the Insurance Department.

     (ii)   The term does not include a grievance.

   Department—The Department of Health of the Commonwealth.

   Drug formulary—A listing of a managed care plan’s preferred therapeutic drugs.

   EQRO—External quality review organization—An entity approved by the Department to conduct an external quality assurance assessment of an HMO.

   Emergency service

     (i)   A health care service provided to an enrollee after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in one or more of the following:

       (A)   Placing the health of the enrollee or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy.

       (B)   Serious impairment to bodily functions.

       (C)   Serious dysfunction of any bodily organ or part.

     (ii)   Transportation and related emergency services provided by a licensed ambulance service shall constitute an emergency service if the condition is as described in subparagraph (i).

   Enrollee—A policyholder, subscriber, covered person or other individual who is entitled to receive health care services under a managed care plan. For purposes of the complaint and grievance processes, the term includes parents of a minor enrollee as well as designees or legal representatives who are entitled or authorized to act on behalf of the enrollee.

   External quality assurance assessment—A review of an HMO’s ongoing quality assurance program and operations conducted by a nonplan reviewer such as a Department-approved EQRO.

   Foreign HMO—An HMO incorporated, approved and regulated in a state other than the Commonwealth.

   Gatekeeper—A primary care provider selected by an enrollee or appointed by a managed care plan, or the plan or an agent of the plan serving as the primary care provider, from whom an enrollee shall obtain covered health care services, a referral or approval for covered nonemergency health services as a precondition to receiving the highest level of coverage available under the managed care plan.

   Gatekeeper PPO—A PPO requiring enrollee use of a gatekeeper from which an enrollee must receive referral or approval for covered health care services as a requirement for payment of the highest level of benefits.


     (i)   A request by an enrollee, or a health care provider with the written consent of the enrollee, to have a managed care plan or CRE reconsider a decision solely concerning the medical necessity and appropriateness of a health care service. If the managed care plan is unable to resolve the matter, a grievance may be filed regarding the decision that does any of the following:

       (A)   Disapproves full or partial payment for a requested health service.

       (B)   Approves the provision of a requested health care service for a lesser scope or duration than requested.

       (C)   Disapproves payment of the provision of a requested health care service but approves payment for the provision of an alternative health care service.

     (ii)   The term does not include a complaint.

   HMO—Health maintenance organization—An organized system that combines the delivery and financing of health care and which provides basic health services to voluntarily enrolled members for a fixed prepaid fee.

   HMO Act—The Health Maintenance Organization Act (40 P. S. § §  1551—1568).

   Health care provider—A licensed hospital or health care facility, medical equipment supplier or person who is licensed, certified or otherwise regulated to provide health care services under the laws of the Commonwealth, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician’s assistant, chiropractor, dentist, pharmacist or an individual accredited or certified to provide behavioral health services.

   Health care service or health service—Any covered treatment, admission, procedure, medical supply, equipment or other service, including behavioral health, prescribed or otherwise provided or proposed to be provided by a health care provider to an enrollee under a managed care plan contract.

   IDS—Integrated delivery system

     (i)   A partnership, association, corporation or other legal entity which does the following:

       (A)   Enters into a contractual arrangement with a plan.

       (B)   Employs or contracts with health care providers.

       (C)   Agrees under its arrangement with the plan to do the following:

         (I)   Provide or arrange for the provision of a defined set of health care services to enrollees covered under a plan contract principally through its participating providers.

         (II)   Assume under the arrangement with the plan some responsibility for conducting in conjunction with the plan and under compliance monitoring of the plan quality assurance, UR, credentialing, provider relations or related functions.

     (ii)   The IDS may also perform claims processing and other functions.

   Inpatient services—Care, including professional services, at a licensed hospital, skilled nursing or rehabilitation facility, including preadmission testing, diagnostic testing related to an inpatient stay, professional and nursing care, room and board, durable medical equipment, ancillary services, drugs administered during an inpatient stay, meals and special diets, use of operating room and use of intensive care and cardiac units.

   Managed care plan or plan

     (i)   A health care plan that does each of the following:

       (A)   Uses a gatekeeper to manage the utilization of health care services.

       (B)   Integrates the financing and delivery of health care services to enrollees by arrangements with health care providers selected to participate on the basis of specific standards.

       (C)   Provides financial incentives for enrollees to use the participating health care providers in accordance with procedures established by the plan.

     (ii)   A managed care plan includes health care arranged through an entity operating under any of the following:

       (A)   Section 630 of the act.

       (B)   The HMO act.

       (C)   The Fraternal Benefit Society Code.

       (D)   40 Pa.C.S. § §  6102—6127 which relates to hospital plan corporations.

       (E)   40 Pa.C.S. § §  6301—6334 which relates to professional health services plan corporations.

     (iii)   The term includes an entity, including a municipality, whether licensed or unlicensed, that contracts with or functions as a managed care plan to provide health care services to enrollees.

     (iv)   The term includes managed care plans that require the enrollee to obtain a referral from any primary care provider in its network as a condition to receiving the highest level of benefits for specialty care.

     (v)   The term does not include ancillary service plans or an indemnity arrangement which is primarily fee for service.

   Medical management—A function that includes any aspect of UR, quality assurance, case management and disease management and other activities for the purposes of determining, arranging, monitoring or providing effective and efficient health care services.

   Member—An enrollee.

   Outpatient services—Outpatient medical and surgical, emergency room and ancillary services including ambulatory surgery and all ancillary services pursuant to ambulatory surgery, outpatient laboratory, radiology and diagnostic procedures, emergency room care that does not result in an admission within 24 hours of the delivery of emergency room care and other outpatient services covered by the plan, including professional services.

   Outpatient setting—A physician’s office, outpatient facility, patient’s home, ambulatory surgical facility, or a hospital when a patient is not admitted for inpatient services.

   PCP—Primary care provider—A health care provider who, within the scope of the provider’s practice, supervises, coordinates, prescribes or otherwise provides or proposes to provide health care services to an enrollee; initiates enrollee referral for specialist care; and maintains continuity of enrollee care.

   POS plan—Point-of-service plan—A health care plan provided by a managed care plan that may require an enrollee to select and utilize a gatekeeper to obtain the highest level of benefits with the least amount of out-pocket expense for the enrollee and that may allow enrollees access to providers inside or outside the network without referral by a gatekeeper.

   Preventive health care services

     (i)   Services provided by the plan to provide for the prevention, early detection and minimization of the ill effects and causes of disease or disability.

     (ii)   The services include prenatal and well baby care, immunizations and periodic physical examinations.

   Provider network—The health care providers designated by a plan to provide health care services to enrollees.

   Secretary—The Secretary of Health of the Commonwealth.

   Service area—The geographic area in which the plan has received approval to operate from the Department.

   UR—Utilization review

     (i)   A system of prospective, concurrent or retrospective review and decisionmaking, performed by a UR entity or managed care plan of the medical necessity and appropriateness of health care services prescribed, provided or proposed to be provided to an enrollee.

     (ii)   The term does not include any of the following:

       (A)   Requests for clarification of coverage, eligibility or health care service verification.

       (B)   A health care provider’s internal quality assurance or UR process unless the review results in denial of payment for a health care service.

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