Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 19 - HEALTH CARE SERVICES ORGANIZATIONS OVERSIGHT › Section R20-6-1902 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
In this Article, the following definitions apply:
"Access" or "accessibility" means the extent to which an
				  enrollee can obtain timely covered services from a contracted provider at the
				  appropriate level of care, and appropriate location.
"Adult" means an enrollee in the age group the HCSO has
				  designated for an adult.
"Adult PCP" means a primary care provider practicing in any
				  specialty the HCSO designates as adult primary care.
"Ancillary provider" means a provider of laboratory,
				  radiology, pharmacy or rehabilitative services, physical therapy, occupational
				  therapy, or speech therapy, home health services, dialysis, and durable medical
				  equipment or medical supplies dispensed by order or prescription of a provider
				  with the appropriate prescribing authority.
"Available" or "availability" means the extent to which the
				  plan has contracted providers of the appropriate type and numbers at geographic
				  locations to afford members access to timely covered services.
"Chief executive officer" or "CEO" means the person who has
				  the authority and responsibility for the operation of the health care services
				  organization according to applicable legal requirements and policies approved
				  by the governing authority.
"Child" means an enrollee in the age group the HCSO has
				  designated for children.
"Contracted" means a provider has a current written agreement
				  or an employment arrangement with an HCSO to provide covered services to an
				  enrollee, or a current written agreement or an employment arrangement with a
				  contracted provider to provide covered services to an enrollee.
"Covered" or "covered services" means the health care
				  services described as covered benefits in the HCSO's evidence of
				  coverage.
"Day" means calendar day unless specified otherwise.
"Department" means the Department of Insurance.
"Effective process" means written policies and procedures
				  that:
Outline the steps that the HCSO implements and consistently
				  follows internally,
The HCSO subjects to internal quality improvement, and
The HCSO communicates to providers when established or
				  changed.
"Emergency services" has the meaning in A.R.S. §
									20-2801(3).
"Enrollee" means an individual who is enrolled in a health
				  plan operated by an HCSO.
"Facility" means an institution that is licensed or
				  authorized to furnish health care services in this state, including general
				  hospitals, special hospitals, residential treatment centers, residential
				  rehabilitation centers, skilled nursing facilities, urgent care centers, and
				  ambulatory surgical treatment centers.
"Governing authority" means a person or body such as a board
				  of trustees or board of directors in whom the ultimate authority and
				  responsibility for the direction of the HCSO is vested.
"HCSO" means a health care services organization.
"Health care services" has the meaning in A.R.S. §
									20-1051(6).
"High profile" means one of no fewer than four specialties
				  designated by the HCSO, and does not include obstetrics-gynecology. An HCSO may
				  designate a specialty as high profile on the basis of high volume or other
				  basis the HCSO reasonably determines is directly related to providing covered
				  services to a member.
"Hospital" means a facility that provides inpatient care,
				  medical services, and continuous nursing services for the diagnosis and
				  treatment of patients.
"Inpatient care" means the covered services that an enrollee
				  who is admitted to a hospital receives for at least 24 consecutive
				  hours.
"Inpatient emergency care" means covered services that would
				  be emergency services if provided in a licensed hospital emergency
				  facility.
"License" means documented authorization issued by the
				  appropriate state of Arizona agency to operate a facility in Arizona, or to
				  practice a health care profession in Arizona.
"Medically necessary" has the meaning set forth in the HCSO's
				  evidence of coverage.
"Network" means the group of providers contracted with an
				  HCSO to provide covered services to an enrollee covered under the HCSO's health
				  benefit plan.
"Network exception" means an enrollee receives covered
				  services from a non-contracted provider either:
Because there is no contracted provider accessible or
				  available that can provide the enrollee timely covered services, or
For any reason the HCSO determines it is in the enrollee's
				  best interests to receive care from a non-contracted provider.
"Non-contracted" means a provider that does not have a
				  contract with an HCSO to provide services to an enrollee.
"Normal business hours" means 8:00 a.m. to 5:00 p.m., Monday
				  through Friday, excluding state or national holidays.
"Outpatient care" means covered services that an enrollee who
				  is not an inpatient receives.
"Pediatric primary care provider" means a physician or
				  practitioner practicing in any specialty the HCSO designates as pediatric
				  primary care.
"Physician" means a licensed doctor of allopathic,
				  chiropractic, optometric, osteopathic, or podiatric medicine.
"Practitioner" means any individual other than a physician
				  who is licensed to furnish health care services, including behavioral health
				  care services, in this state.
"Preventive care" means health maintenance care the HCSO
				  provides or arranges to prevent illness and to improve the general health of an
				  enrollee, including:
Immunizations,
Health education,
Health evaluation and follow-up,
Early disease detection,
Screening tests appropriate for a person's age and gender,
				  and
Periodic health care examinations.
"Primary care" means any specialty the HCSO designates as
				  primary care.
"Primary care physician" or "PCP" means a physician or
				  practitioner practicing in a specialty the HCSO designates as primary
				  care.
"Provider" means any physician, practitioner, ancillary
				  provider, or facility.
"Quality improvement" means an HCSO's system for assessing
				  and improving the level of performance of key process and outcomes.
"Routine care" means covered primary care for an enrollee's
				  non-urgent, symptomatic condition.
"Rural" means a zip code area with fewer than 1,000 persons
				  per square mile as calculated annually by a population data gathering service
				  designated by the Director.
"Service area" means any geographic area designated by any
				  HCSO and approved by the Director under A.R.S. §
									20-1053(A)(11).
"Specialty care provider" or "SCP" means a physician or
				  practitioner who has education, training, or qualifications in a specialty,
				  other than primary care, beyond the education or qualifications required for
				  the license.
"Specialty" or "specialty care" means a specific area of
				  medicine practiced by a physician or practitioner who has education, training,
				  or qualifications in that specific area of medicine in addition to the
				  education or qualifications required for the physician's or practitioner's
				  license.
"Special hospital" means a hospital that is licensed to
				  provide hospital services within a specific area of medicine, or limits patient
				  admission according to age, gender, type of disease, or medical
				  condition.
"Suburban area" means any zip code area with 1,000-3,000
				  persons per square mile, as calculated annually by a population data gathering
				  service designated by the Director.
"Telemedicine" means diagnostic, consultation, and treatment
				  services that occur in the physical presence of an enrollee on a real-time
				  basis through interactive audio, video, or data communication.
"Timely" means services are provided at the time when
				  medically necessary.
"Travel expenses" has the meaning set forth in writing by an
				  HCSO.
"Urban area" means a zip code with more than 3,000 persons
				  per square mile as calculated annually by a population data gathering service
				  designated by the Director.
"Urgent care" means unscheduled services for an enrollee's
				  condition that requires medical attention not amenable to scheduling in order
				  to avoid a serious risk of harm.