Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-1 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words or terms used in the Subchapter shall
				  have the following meaning, unless the context clearly indicates
				  otherwise:
"Adverse benefit determination"
means a
				  determination by a health carrier or its designee utilization review
				  organization that an admission, availability of care, continued stay, or other
				  health care service that is a covered benefit has been reviewed and, based upon
				  the information provided, does not meet the health carrier's requirements for
				  medical necessity, appropriateness, health care setting, level of care or
				  effectiveness, and the requested service or payment for the service is
				  therefore denied, reduced or terminated and in accordance with Title 36 of
				  Oklahoma Statute (O.S.) §
									6475.3.
"Appeal"
means a review of an adverse benefit
				  determination performed by a managed care entity or according to managed care
				  law, regulations, and contracts.
"Exigent circumstances"
means a situation in
				  which a reasonable person applying the appropriate standard would consider a
				  member's health condition to be urgent with identifiable harm that could
				  reasonably be expected to occur if the requested health care service is not
				  provided promptly. The appropriate standard requires the assessment of a
				  member's health condition through application, at minimum, of established,
				  accepted standards of medical practice. Evidence of the member's condition may
				  be demonstrated by indications from the treating provider or from the member's
				  medical record, including but not limited to such information as the member's
				  diagnosis, symptoms, or test results.
"Grievance"
means a member's expression of
				  dissatisfaction about any managed care program matter other than an adverse
				  benefit determination and may include, but is not limited to, the quality of
				  care or services provided, aspects of interpersonal relationships such as
				  rudeness of a managed care entity employee or contracted provider, or failure
				  to respect the member's rights regardless of whether remedial action is
				  requested. A grievance includes a member's right to dispute an extension of
				  time to make an authorization decision when proposed by the managed care
				  entity.
"Health plan"
means any person or entity that is
				  licensed as a health maintenance organization (HMO) by the State of Oklahoma to
				  provide or arrange for the delivery of basic health care services to enrollees
				  on a prepaid basis, except for copayments or deductibles for which the enrollee
				  is responsible, or both, that meets the definition of an HMO as delineated in
				  the Oklahoma State Medicaid Plan and that contracts with the State to provide
				  services to enrollees. "Health plan" is synonymous with "health
				  carrier".
"Managed care entity"
or
"MCE"
means any entity permitted under 42 C.F.R. Part 438 to contract with a state
				  for services provided under a risk contract or a nonrisk contract within the
				  state's Medicaid managed care program, including but not limited to managed
				  care organization (MCO), primary care case management (PCCM), primary care case
				  management entity (PCCM entity), prepaid ambulatory health plan (PAHP), and
				  prepaid inpatient health plan (PIHP).
"Managed care organization"
or
"MCO"
means the same in these rules as defined at
				  42
				  Code of Federal Regulations (C.F.R.) §
										438.2.
"Managed care program"
or
"managed
				  care"
or
"MCP"
means a health care delivery system
				  organized to manage cost, utilization, and quality that is operated by a state
				  as authorized under sections 1915(a), 1915(b), 1932(a), or 1115(a) of the
				  Social Security Act and relevant state law.
"Member"
means an individual eligible for
				  Medicaid in the State of Oklahoma, eligible for a managed care program, and
				  enrolled in a managed care entity. "Member" is synonymous with "health plan
				  enrollee".
"Prepaid ambulatory health plan"
or
"PAHP"
means the same in these rules as defined at
				  42
				  C.F.R. §
										438.2.
"Prepaid inpatient health plan"
or
"PIHP"
means the same in these rules as defined at
				  42
				  C.F.R. §
										438.2.
"Primary care case management"
or
"PCCM"
means the same in these rules as defined at
				  42
				  C.F.R. §
										438.2.
"Primary care case management entity"
or
"PCCM entity"
means the same in these rules as defined at
				  42
				  C.F.R. §
										438.2.
"Prior authorization (PA)"
means a requirement
				  that a member, through a provider, obtain the managed care entity's approval
				  before a requested medical service is provided or before services by a
				  non-participating provider are received. Prior authorization is not a guarantee
				  of claims payment; however, failure to obtain prior authorization may result in
				  denial of the claim or reduction in payment of the claim. For purposes of these
				  rules, "prior authorization" is included as a determination of health care
				  services within the term "adverse benefit determination".
"Provider"
means a health care or dental
				  provider licensed or certified in this state.