Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 55 - Managed Care › Subchapter 1 - General Provisions › Section 317:55-1-3 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
				  will have the following meaning, unless the context clearly indicates
				  otherwise:
"1115 waiver"
means the demonstration waiver, as
				  amended and including all active special terms and conditions (STCs) at a
				  specific point in time, that authorizes Oklahoma Health Care Authority (OHCA)
				  to operate a program in which one or more requirements of Title XIX of the
				  Social Security Act (Act) are waived based on the waiver authority of section
				  1115 of the Act.
"1915(c) waiver"
means any waiver, authorized by
				  section 1915(c) of the Act, that allows specific coverage of home- and
				  community-based services to a limited group of Medicaid-eligible individuals as
				  an alternative to institutional care.
"Accountable care organization"
or
"ACO"
means a group of clinicians, hospitals, or other health care
				  providers who come together voluntarily to give coordinated high-quality care
				  to a designated group of patients.
"Act"
means the Social Security Act.
"Adult"
means an individual twenty-one (21)
				  years of age or older, unless otherwise specified by statute, regulation,
				  and/or policy adopted by the OHCA. For eligibility criteria policy for children
				  and adults, please refer to Oklahoma Administrative Code (OAC)
				  317:35-5-2.
"Adverse determination"
means a determination by
				  a health carrier, including an managed care organization (MCO) or dental
				  benefits manager (DBM), or its designee 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 services is therefore denied, reduced or terminated.
"Alternative benefit plan"
means the benefit
				  package delivered to expansion adults which is developed by OHCA and approved
				  by the Centers for Medicare and Medicaid Services (CMS) in accordance with the
				  requirements of Subpart C of 42 C.F.R. Part 440 .
"American Indian/Alaska Native"
or
"AI/AN"
means any individual as defined in
				  25
				  U.S.C. §§
										1603(13),
				  1603(28)
				  or
				  1679(a)
				  or who has been determined eligible as an Indian under
				  42 C.F.R. §
										136.12.
"Appeal"
means a review by an MCO or DBM of an
				  adverse benefit determination.
"Authorized representative"
means a competent
				  adult who has the managed care enrollee's signed, written authorization to act
				  on the managed care enrollee's behalf during the grievance, appeal, and State
				  fair hearing process. The written authority to act will specify any limits of
				  the representation.
"Capitation payment"
means a payment, based on
				  an actuarially sound capitation rate for the provision of Oklahoma Medicaid
				  State Plan services under a managed care contract, that OHCA makes periodically
				  to the MCO or DBM behalf of each enrollee enrolled in that MCO or DBM,
				  regardless of whether the enrollee actually receives services during the period
				  covered by the payment.
"Capitation rate"
means the actuarially sound
				  per-enrollee, per-month amount, including any adjustments, that OHCA agrees to
				  pay an MCO or DBM for the provision of State Plan services.
"Child"
means an individual under twenty-one
				  (21) years of age, unless otherwise specified by statute, regulation, and/or
				  policy adopted by the OHCA. For eligibility criteria policy for children and
				  adults, please refer to OAC
				  317:35-5-2.
"Children's Health Insurance Program"
or
"CHIP"
means a federal Medicaid program authorized under Title XXI
				  of the Social Security Act.
"Choice counseling"
means the provision of
				  information and services designed to assist eligibles in making enrollment
				  decisions related to the managed care program. Choice counseling includes
				  answering questions and identifying factors to consider when choosing among
				  MCOs or DBMs, as well as when choosing a patient-centered medical home provider
				  or dental home provider. Choice counseling does not include making
				  recommendations for or against enrollment into a specific MCO or DBM.
"Chronic condition"
means a condition that is
				  expected to last one (1) year or more and requires ongoing medical attention
				  and/or limits activities of daily living (ADL).
"Civil monetary damage"
means a damage imposed
				  by OHCA which the MCO must pay for acting or failing to act in accordance with
				  42 C.F.R. §
										438.700 et seq. Amounts may not exceed those
				  specified in
				  42 C.F.R. §
										438.704.
"Claims denial error rate"
means the rate of
				  claims denials that are overturned on appeal.
"Clean claim"
means a properly completed billing
				  form with coding based on Current Procedural Terminology (CPT), 4th Edition or
				  a more recent edition, the Tenth Revision of the International Classification
				  of Diseases or a more recent revision, or Healthcare Common Procedure Coding
				  System (HCPCS), where applicable, to provide information specifically required
				  in the OHCA Provider Billing and Procedure Manual.
" C.F.R."
means the Code of Federal
				  Regulations.
"Contract"
means the risk contract or the
				  written and executed agreement between OHCA and a health plan or managed care
				  organization or dental benefit manager for health plan or managed care services
				  and includes the solicitation, the bid, the contract addenda, appendices,
				  attachments, and amendments, and any documents incorporated into the contract
				  by reference or otherwise, as well as any document or information subject to
				  the rules on legally binding procurement in Chapter 10 of these rules.
"Copayment"
means a fixed amount that an
				  enrollee pays for a covered health care service when the enrollee receives the
				  service.
"Cost sharing"
means the State's requirement
				  that an enrollee bear some of the cost of their care through mechanisms such as
				  copayments, deductibles, and other similar charges.
"Deemed newborn"
means children born to
				  SoonerCare enrolled mothers and determined eligible under
				  42 C.F.R. §
										435.117.
"Dental benefits manager"
or
"DBM"
means a health plan under contract with the OHCA to manage and deliver dental
				  benefits and services to enrollees and designated as a pre-paid ambulatory
				  health plan (PAHP) under 42 C.F.R. Part 438 .
"Dental home"
or
"DH"
means the
				  care coordinated delivery system as defined within the contract between OHCA
				  and a DBM.
"Disenrollment"
means OHCA's removal of an
				  enrollee from participation in a specific MCO or DBM or from participation in
				  the managed care program.
"Dual eligible individuals"
means individuals
				  eligible for both Medicaid and Medicare.
"Eligible"
means an individual who has been
				  deemed eligible for Medicaid in the State of Oklahoma and is eligible for
				  participation in the managed care program but who is not yet enrolled in an MCO
				  or DBM.
"Emergency services"
means medical services
				  provided for a medical condition, including injury, manifesting itself by acute
				  symptoms of sufficient severity, including severe pain, 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
				  placing the individual's health, or the health of an unborn child, in serious
				  jeopardy, serious impairment to bodily functions or serious dysfunction of any
				  bodily organs or parts.
"Enrollee"
means an individual who has been
				  deemed eligible for Medicaid in the State of Oklahoma, who has been deemed
				  eligible for enrollment in a managed care program, and who is currently
				  enrolled in a managed care program.
"Enrollee handbook"
means a guidebook prepared
				  as a model by OHCA and modified and distributed by the MCO or DBM to its
				  enrollees. The enrollee handbook is designed to help the enrollee understand
				  the MCO or DBM, the managed care program, and the rights and responsibilities
				  that come with enrollment in the program.
"Enrollment"
means the OHCA process by which an
				  eligible becomes an enrollee with an MCO or DBM.
"Enrollment activities"
means activities that
				  OHCA performs or conducts related to distributing, collecting, or processing
				  enrollment materials, taking enrollments by technological device or in person,
				  or enrolling or disenrolling eligibles into any MCO or DBM.
"Essential community provider"
means a provider
				  defined by
				  45 C.F.R. §
										156.235.
"Essential hospital services"
means tertiary
				  care hospital services to which the MCO must provide access, including but not
				  limited to neonatal, perinatal, pediatric, trauma and burn services.
"Expansion adult"
means an individual nineteen
				  (19) or older and under age sixty-five (65), with income at or below one
				  hundred thirty-eight percent (138%) of the federal poverty level (FPL)
				  determined eligible in accordance with
				  42
				  C.F.R. §
										435.119) , and who are not
				  categorically related to the aged, blind, and disabled.
"Former foster children"
or
"FFC"
means individuals under age twenty-six (26) determined eligible in accordance
				  with
				  42 C.F.R. §
										435.150 who were in foster care under the
				  responsibility of the State or an Indian Tribe within Oklahoma and enrolled in
				  SoonerCare on the date of attaining age eighteen (18) or aging out of foster
				  care.
"Foster children (FC)"
means children in foster
				  care under the responsibility of the State, including children and youth who
				  are in State custody due to abuse or neglect.
"Fraud"
means intentional deception or
				  misrepresentation made by a person with the knowledge that the deception could
				  result in some unauthorized benefit to himself or some other person. It
				  includes any act that constitutes fraud under applicable federal or State law.
"Grievance"
means an enrollee's expression of
				  dissatisfaction about any matter other than an adverse benefit determination.
				  Grievances may include, but are not limited to, the quality of care or services
				  provided, aspects of interpersonal relationships such as rudeness of a provider
				  or employee or failure to respect the enrollee's rights regardless of whether
				  remedial action is requested. A grievance includes an enrollee's right to
				  dispute an extension of time to make an authorization decision when proposed by
				  the MCO or DBM.
"Grievance and appeal system"
means the
				  processes the MCO or DBM must implement in accordance with 42 C.F.R. Part 438 ,
				  Subpart F, to handle enrollee grievances and appeals, as well as the processes
				  to collect and track information about them.
"Health care services"
means all Medicaid State
				  Plan services provided, according to contract, by the MCO or DBM in any
				  setting. Health care services may include but are not limited to medical care,
				  behavioral health care, dental care, and pharmacy services.
"Health plan"
means the same in these rules as
				  at 36 O.S. § 4405.1.
"Implementation"
means the process by which OHCA
				  and the MCO or DBM performs actions and responsibilities to actively implement
				  a managed care program or contract for the first time. Implementation also
				  means, depending on its use, the moment in time that such actions and
				  responsibilities are fully completed.
"Implementation period"
means the period of
				  time, as defined in contract, during which implementation occurs.
"Indian health care provider"
or
"IHCP"
means a health care program operated by the Indian Health
				  Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian
				  Organization (otherwise known as an I/T/U) as those terms are defined in
				  section 4 of the Indian Health Care Improvement Act (25 U.S.C. §
										1603) .
"Initial enrollment"
means an eligible's
				  enrollment in an MCO or DBM during the initial enrollment period.
"Initial enrollment period"
means the first
				  period of time, as defined in contract, prior to or immediately following
				  managed care program or contract implementation, when eligibles can first
				  enroll in an MCO or DBM for the managed care program.
"Managed care organization"
or
"MCO"
means a health plan designated as a managed care
				  organization pursuant to
				  42
				  C.F.R. 438.2 and under contract with OHCA to
				  participate in the managed care program and to deliver health care services to
				  enrollees.
"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.
"Manual"
or
"guide"
means any
				  document, outside of the Medicaid State Plan, any Medicaid waiver, and the
				  rules, that is created by or for OHCA for use in interpreting or implementing
				  contractual terms. "Manual" is synonymous with guide, guidebook, companion
				  guide, manual, reference book, dictionary, handbook, model, instructions,
				  primer, workbook, or any other words denoting a document that is handled as a
				  matter of convenience.
"Material change"
means, but not limited to, any
				  change in the overall business operations such as policy, process or protocol
				  which affects, or can reasonably be expected to affect, more than five percent
				  (5%) of enrollees or participating providers of the MCO or DBM.
"Medical necessity"
means a standard for
				  evaluating the appropriateness of services as established under OAC
				  317:30-3-1.
"National Provider Identifier (NPI)"
means a
				  unique identification number for covered health care providers. Covered health
				  care providers and all MCOs, DBMs, and health care clearinghouses must use an
				  NPI in the administrative and financial transactions adopted under the Health
				  Insurance Portability and Accountability Act (HIPAA). The NPI is a
				  ten-position, intelligence-free numeric identifier (ten-digit number). This
				  means that the numbers do not carry other information about healthcare
				  providers, such as the state in which they live or their medical specialty. The
				  NPI must be used in lieu of legacy provider identifiers in the HIPAA standards
				  transactions.
"Non-participating provider"
means a physician
				  or other provider who has not contracted with or is not employed by the MCO or
				  DBM to deliver services under the managed care program.
"Non-urgent sick visit"
means medical care given
				  for an acute onset of symptoms which is not emergent or urgent in nature but
				  which requires face-to-face medical attention within seventy-two (72) hours of
				  enrollee notification of a non-urgent condition, as clinically indicated.
				  Examples of non-urgent sick visits include cold symptoms, sore throat, and
				  nasal congestion.
"Open enrollment"
means an eligible's selection
				  of and enrollment in an MCO or DBM during the open enrollment period.
"Open enrollment period"
means the annual period
				  of time, as defined by contract, when managed care enrollees and eligibles can
				  enroll in and select an MCO or DBM for the managed care program.
"Parent and caretaker relative"
means an
				  individual determined eligible under
				  42 C.F.R. §
										435.110.
"Participating provider"
means a physician or
				  other provider who has a contract with or is employed by an MCO or DBM to
				  provide health care services to enrollees under the capitated managed care
				  delivery model of the managed care program.
"Patient-centered medical home"
or
"PCMH"
means, in this chapter, the care coordinated delivery
				  system as defined within the contract between OHCA and an MCO.
"Pregnant women"
means women determined eligible
				  for SoonerCare under
				  42 C.F.R. §
										435.116.
"Presumptive eligibility"
means limited period
				  of managed care program eligibility for individuals who are categorically
				  related to certain eligibility groups listed in OAC
				  317:35-6-38(a)(1)(A)(i)
				  through (vi) and are also determined by a
				  qualified hospital, on the basis of preliminary information provided by the
				  applicant on a completed HPE application, to be eligible for managed care
				  program services.
"Primary care dentist"
or
"PCD"
means a provider under contract with a DBM to provide primary health care
				  services, as contracted, and case management, including all medically necessary
				  referrals for specialty services and prior authorizations. In these rules,
				  "dental home provider" or "DH provider" bears the same meaning as "primary care
				  dentist" or "PCD".
"Primary care provider"
or
"PCP"
means a provider under contract with an MCO to provide primary health care
				  services, as contracted, and case management, including securing all medically
				  necessary referrals for specialty services and prior authorizations. In these
				  rules, "patient-centered medical home provider" or "PCMH provider" bears the
				  same meaning as "primary care provider" or "PCP".
"Prior authorization"
or
"PA"
means
				  a requirement that an enrollee, through the enrollee's provider, obtain the
				  MCO's or DBM'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.
"Provider"
means a health care services provider
				  licensed or certified in this State.
"Provider agreement"
means an agreement between
				  the MCO or DBM and a participating provider that describes the conditions under
				  which the participating provider agrees to furnish covered health care services
				  to enrollees.
"Risk contract"
means a contract between OHCA
				  and an MCO, prepaid inpatient health plan (PIHP), or prepaid ambulatory health
				  plan (PAHP), as those terms are defined at
				  42
				  C.F.R. §
										438.2, under which the
				  contractor assumes risk for the cost of the services covered under the contract
				  and incurs loss if the cost of furnishing the services exceeds the payments
				  under the contract.
"SoonerCare"
means the Oklahoma Medicaid
				  program.
"Soon-To-Be-Sooner"
means Oklahoma's separate
				  CHIP providing coverage to unborn children of families earning up to and
				  including one hundred eighty-five percent (185%) of the FPL.
"Specialty Children's Plan"
means the single
				  statewide managed care plan, as contracted with a single MCO, that will
				  coordinate and deliver health care services, as defined by contract, in a
				  highly coordinated manner to the specialty population. The specialty population
				  includes Medicaid eligibles who are FFC, select juvenile justice involved
				  Office of Juvenile Affairs (OJA), in foster care (FC), children with an open
				  prevention services case (PSC) through case workers or receiving adoption
				  assistance (AA).
"State Plan"
means an agreement between OHCA and
				  CMS describing how Oklahoma administers its Medicaid and CHIP programs.
"Steady state enrollment"
means the period of
				  time, as defined by contract, when an individual, who first became an eligible
				  during steady state operations or who became eligible again during steady state
				  operations after more than two (2) months lapse of eligibility, can first
				  enroll in and select an MCO or DBM for the managed care program.
"Steady state operations"
or
"steady
				  state"
means the period of time, as defined by contract, after initial
				  implementation and prior to contract termination, during which all managed care
				  program elements are expected to be operational.
"Third party liability"
or
"TPL"
means all or part of the expenditures for a managed care enrollee's medical
				  assistance furnished under the Oklahoma Medicaid State Plan that may be the
				  liability of a third-party individual, entity or program.
"Value-added benefit"
means any benefit or
				  service offered by an MCO or DBM when that benefit or service is not a covered
				  benefit per the State Plan. These benefits are subject to change annually as
				  determined by the MCO or DBM and OHCA.
"Value-based payment arrangement"
means a
				  payment arrangement between an MCO or DBM and its participating providers when
				  payment is intentionally aligned with quality measures OHCA applies to the MCO
				  or DBM.
"Value-based purchasing"
means the provisions of
				  a contract for managed care services when those provisions intentionally align
				  OHCA payments to the MCO or DBM under contract with quality measures or other
				  performance factors OHCA may apply to the MCO or DBM.