Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 240 - HEALTH MAINTENANCE ORGANIZATIONS CODE › Subpart A - GENERAL PROVISIONS › Section 240.20 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Act" means the Health Maintenance Organization Act (Ill.
				  Rev. Stat. 1987, ch. 1111/2, pars. 1401 et seq.).
"Basic health care services" means emergency care, and
				  inpatient hospital and physician care, outpatient medical services, mental
				  health services and care for alcohol and drug abuse, including any reasonable
				  deductibles and co-payments. (See also the Department of Insurance regulations
				  located at 50 Ill. Adm. Code 6101.130.) (Section 1-2 of the Act)
"Director of Department of Public Health" means the Director
				  of the Illinois Department of Public Health, or such person or office as
				  designated by the Director of the Department of Public Health to act in the
				  Director's behalf.
"Encounter" means a face to face contact between an enrollee
				  and a basic health care service provider who has primary responsibility for
				  assessing and treating the condition of the patient at a given contact and
				  exercises independent judgement in the care of the enrollee.
"Enrollee" or "member" means an individual who has been
				  enrolled as a subscriber or as an eligible dependent of a subscriber and for
				  whom the HMO has accepted the contractual responsibility for providing or
				  arranging for at least, health care services and basic health care
				  services.
"Evidence of Coverage" means any certificate, agreement, or
				  contract issued to an enrollee setting out the coverage to which he is entitled
				  in exchange for a per capita prepaid sum. (Section 1-2 of the Act)
"Grievance" means any written complaint by an enrollee
				  regarding any aspect of the HMO relative to the enrollee. (See also the
				  Department of Insurance regulations on HMO's, 50 Ill. Adm. Code 6101.40 for
				  clarification.)
"Health Care Plan" means any arrangement whereby any
				  organization undertakes to provide, arrange for and pay for or reimburse the
				  cost of basic health care services and at least part of such arrangement
				  consists of arranging for or the provision of health care services, as
				  distinguished from mere indemnification against the cost of such services, on a
				  prepaid basis, through insurance or otherwise. (Section 1-2 of the Act)
"Health Care Services" means any services included in the
				  furnishing to any individual of medical or dental care, or the hospitalization
				  or incident to the furnishing of such care or hospitalization as well as the
				  furnishing to any person of any and all other services for the purpose of
				  preventing, alleviating, curing or healing human illness or injury. (Section
				  1-2 of the Act)
"Health Maintenance Organization" or "HMO" means any
				  organization formed under the laws of this or another state to provide or
				  arrange for one or more health care plans under a system which causes any part
				  of the risk of health care delivery to be borne by the organization or its
				  providers. (Section 1-2 of the Act)
"Medical Director" means a physician licensed to practice
				  medicine in all its branches in Illinois and who shall be responsible for final
				  review when questions of medical practice arise in the HMO in order to assure
				  the quality of health care services provided.
"Peer Review" means the evaluation
by similarly licensed practicing physicians of the
				  effectiveness and efficiency of services ordered or performed by other
				  similarly licensed practicing physicians, or
by other professionals of the effectiveness and efficiency of
				  services ordered or performed by other members of the profession whose work is
				  being reviewed.
"Plan Service Area" means the geographic territory to be
				  served by the HMO.
"Primary Care Physician" means a provider who has contracted
				  with a Health Maintenance Organization to provide primary care services as
				  defined by the contract and who is
a physician licensed to practice medicine in all of its
				  branches who spends a majority of clinical time engaged in general practice or
				  in the practice of internal medicine, pediatrics, gynecology, obstetrics or
				  family practice, or
a chiropractic physician licensed to treat human ailments
				  without the use of drugs or operative surgery.
"Provider" means any physician, hospital facility, or other
				  person which is licensed by state law or otherwise authorized by state,
				  federal, or local law to furnish health care services. (Section 1-2 of the
				  Act)
"Quality Assessment Monitoring" means the planned,
				  systematic, and routine collection of information by the HMO according to
				  previously determined indicators of quality and appropriateness of patient care
				  and clinical performance encompassing basic and supplemental health care
				  services and providers. After periodic assessment and evaluation by the HMO,
				  quality assessment monitoring can detect trends and identify opportunities for
				  improving enrollees' care.
"Supplemental Benefits" or "Selective Benefits" means any
				  services or benefits provided by the HMO over and above those required as basic
				  health care services.
"Utilization Review" means the study of the appropriateness
				  of the use of particular services and the appropriateness of the volume of
				  services used.