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,
				  shall 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 (1) 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.
"Abuse"
means provider practices that are
				  inconsistent with sound fiscal, business, or medical practices, and result in
				  an unnecessary cost to the Medicaid program, or in reimbursement for services
				  that are not medically necessary or that fail to meet professionally recognized
				  standards for health care (as defined at
				  42 C.F.R. §
										455.2). It also includes Eligible and Health
				  Plan Enrollee practices that result in unnecessary cost to the Medicaid
				  program.
"Accountable care organization"
or
"ACO"
means a network of physicians, hospitals, and other health
				  care providers that provide coordinated care to Medicaid members.
"Accrediting entity"
means an entity recognized
				  by CMS under 45 C.F.R.
				  §
										156.275. Current CMS-recognized
				  accrediting entities include Accreditation Association for Ambulatory Health
				  Care (AAAHC), National Committee for Quality Assurance (NCQA) and Utilization
				  Review Accreditation Commission (URAC). To the extent CMS recognizes additional
				  accrediting entities, OHCA will also permit the CE or DBM to achieve
				  accreditation from such entity to meet the requirements.
"Act"
means the Social Security Act.
"Activities of daily living (ADL)"
means
				  activities that reflect the Health Plan Enrollee's ability to perform self-care
				  tasks essential for sustaining health and safety such as: bathing; eating;
				  dressing; grooming; transferring (includes getting in and out of the tub, bed
				  to chair, etc.); mobility; toileting and bowel/bladder control. The services
				  help with proper medical care, self-maintenance skills, personal hygiene,
				  adequate food, shelter, and protection.
"Administrative remedies"
means an action taken
				  by the OHCA in response to the DBM's failure to comply with a requirement or
				  performance standard. Remedies, include but are not limit to, liquidated
				  damages, capitation payment suspension, auto-assignment suspension, contract
				  termination, and any other remedies outlined in the Contract.
"Adult"
means an individual twenty-one (21)
				  years of age or older, unless otherwise specified by statute, regulation,
				  and/or policy Amended by the OHCA. For eligibility criteria policy for children
				  and adults, please refer to Oklahoma Administrative Code (OAC)
				  317:35-5-2.
"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 CE or DBM of an
				  adverse benefit determination.
"Applicant"
means an individual who seeks
				  SoonerCare coverage.
"Authorized representative"
means a competent
				  adult who has the Enrollee's signed, written authorization to act on the
				  Enrollee's behalf during the grievance, appeal, and state fair hearing process.
				  The written authority to act will specify any limits of the representation.
"Behavioral health services"
means a wide range
				  of diagnostic, therapeutic and rehabilitative services used in the treatment of
				  mental illness, substance abuse, and co-occurring disorders.
"Business days"
means Monday through Friday and
				  is exclusive of weekends and State of Oklahoma holidays.
"Calendar days"
means all seven (7) days of the
				  week, including State of Oklahoma holidays.
"Capitated contract"
means a contract between
				  OHCA and a contracted entity for the delivery of services to Medicaid members
				  in which OHCA pays a fixed, per-member per-month rate based on actuarial
				  calculations.
"Capitation payment"
means a payment OHCA will
				  make periodically to the CE or DBM on behalf of each Health Plan Enrollee
				  enrolled under the SoonerSelect program and based on the actuarially sound
				  capitation rate for the provision of services under the State Plan. OHCA shall
				  make the payment regardless of whether the Health Plan Enrollee receives
				  services during the period covered by the payment.
"Capitation rate"
means the per Health Plan
				  Enrollee, per-month amount, including any adjustments, that is paid by OHCA to
				  the CE or DBM for each Health Plan Enrollee enrolled in the SoonerSelect
				  program for the provision of services during the payment period.
"Care coordination/care management"
means a
				  process that assesses, plans, implements, coordinates, monitors, and evaluates
				  the options and services required to meet the Health Plan Enrollee's needs
				  using advocacy, communication, and resource management to promote quality and
				  cost-effective interventions and outcomes. Based on the needs of the Health
				  Plan Enrollee, the care manager arranges services and supports across the
				  continuum of care, while ensuring that the care provided is person-centered.
"Care manager"
means the CE's staff primarily
				  responsible for delivering services to Health Plan Enrollees in accordance with
				  its OHCA-approved risk stratification level framework, and meets the
				  qualifications specified in the Contract.
"Care plan"
means a comprehensive set of actions
				  and goals for the Health Plan Enrollee developed by the care manager based on
				  the unique needs of Health Plan Enrollee(s). The CE shall develop and implement
				  care plans for all Health Plan Enrollees with a special health care need
				  determined through the comprehensive assessment to need a course of treatment
				  or regular care monitoring and in accordance with Section 1.8.3: "Care Plans"
				  of the Contract.
"Case file"
means an electronic record that
				  includes Enrollee information regarding the management of health care services
				  including but not limited to: Enrollee demographics; comprehensive assessment
				  (if applicable); care plan; reassessments; referrals and authorizations and
				  Enrollee case notes.
"CDT"
means current dental terminology (dental
				  procedure codes).
"CEO"
means Chief Executive Officer.
"Certified community behavioral health clinic
				  (CCBHC)"
means entities designed to provide a comprehensive range of
				  mental health and substance use disorder services as defined under the
				  Excellence in Mental Health Act and certified by the Oklahoma Department of
				  Mental Health and Substance Abuse Services.
"C.F.R."
means the Code of Federal Regulations.
"Child"
means an individual under twenty-one
				  (21) years of age, unless otherwise specified by statute, regulation, and/or
				  policy Amended 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 Medicaid program authorized under Title XXI of the
				  Social Security Act.
"Children's Specialty Plan"
or
"Children's
				  Specialty Program"
means the single statewide health care plan that
				  covers all Medicaid services other than dental services and is designed to
				  provide care to children in foster care children, former foster care children
				  up to twenty-five (25) years of age, juvenile justice involved children, and
				  children receiving adoption assistance.
"Child welfare services"
means the Oklahoma
				  Human Services (OKDHS) division responsible for administering Oklahoma's child
				  welfare services.
"Choice counseling"
means the provision of
				  information and services designed to assist Eligibles in making enrollment
				  decisions as described in 42
				  C.F.R §
										438.2.
"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 CE 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.
"Clean claim"
means a properly completed billing
				  form with coding based on Current Procedural Terminology (CPT), fourth edition
				  or a more recent edition, the tenth revision of the International
				  Classification of Diseases (ICD) 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.
"Clinical practice guidelines"
means
				  systematically developed statements to assist practitioner and patient
				  decisions about appropriate health care for specific clinical circumstances.
				  The CE or DBM shall adopt clinical practice guidelines in accordance with
				  42 C.F.R. §
										438.236, ensuring they are based on valid and
				  reliable clinical evidence or a consensus of providers in the particular field;
				  consider the needs of Enrollees; are adopted in consultation with participating
				  providers; and are reviewed and updated periodically as appropriate.
"CMS"
means Centers for Medicare & Medicaid
				  Services.
"Commercial plan"
means an organization or
				  entity that undertakes to provide or arrange for the delivery of health care
				  services to Medicaid members on a prepaid basis and is subject to all
				  applicable state and federal laws and regulations.
"Continuity of care period"
means the ninety
				  (90) day period immediately following an Enrollee's enrollment with the CE or
				  DBM whereby established Enrollee and provider relationships, current services
				  and existing prior authorizations and care plans shall remain in place.
"Contract"
mean a result of receiving an award
				  from OHCA and successfully meeting all Readiness Review requirements, the
				  agreement between the Contractor and OHCA where the Contractor will provide
				  Medicaid services to SoonerSelect Enrollees, comprising of the Contract and any
				  Contract addenda, appendices, attachments, or amendments thereto, and be paid
				  by OHCA as described in the terms of the agreement.
"Contract year"
means the period during which
				  the Contract is in effect. The initial Contract year shall be from date of
				  award through the end of the state fiscal year. Each subsequent Contract year
				  shall be based on state fiscal year.
"Contracted entity"
or
"CE"
means
				  an organization or entity that enters into or will enter into a capitated
				  contract with the Oklahoma Health Care Authority (OHCA) for the delivery of
				  services that will assume financial risk, operational accountability, and
				  statewide or regional functionality in this act in managing comprehensive
				  health outcomes of Medicaid members. This includes an accountable care
				  organization, a provider-led entity, a commercial plan, a dental benefit
				  manager, or any other entity as determined by the OHCA.
"Contractor"
means a contracted entity with
				  which OHCA has entered into a binding agreement for the purpose of procuring
				  services to SoonerSelect program Enrollees as specified in the Contract. The
				  term "Contractor" includes all such Contractor's affiliates, agents,
				  subsidiaries, any person with an ownership or control interest, officers,
				  directors, manager, employees, independent contractors, and related parties
				  working for or on behalf of the Contractor and other parties.
"Copayment"
means a fixed amount that an
				  Enrollee pays for a covered health care service when the Enrollee receives the
				  service.
"Corrective action plan"
or
"CAP"
means the detailed written plan that may be required by OHCA to correct or
				  resolve a deficiency, event, or breach.
"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.
"Credibility adjustment"
means an adjustment to
				  the medical loss ratio (MLR) for a partially credible CE or DBM to account for
				  a difference between the actual and target MLRs that may be due to random
				  statistical variation.
"Crisis intervention services"
means
				  face-to-face services for the purpose of responding to acute behavioral or
				  emotional dysfunction as evidenced by psychotic, suicidal, homicidal severe
				  psychiatric distress and/or danger of alcohol or drug relapse.
"Critical incident"
means any actual or alleged
				  event or situation that creates a significant risk of substantial or serious
				  harm to the physical or mental health, safety, or well-being of a SoonerSelect
				  program Health Plan Enrollee.
"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 an entity that meets the definition of a Prepaid Ambulatory Health Plan
				  (PAHP) as per 42 C.F.R.
				  §
										438.2 and is under contract with the
				  OHCA to manage and deliver all services described in this SoonerSelect Dental
				  Contract and who handles claims payment and prior authorizations and
				  coordinates dental care with participating providers and Enrollees. Also
				  referred to as a "Contractor".
"Dental related emergency services"
means
				  services provided to a SoonerSelect Dental Enrollee that are necessary for the
				  treatment of any condition requiring immediate attention for the relief of
				  pain, hemorrhage, acute infections, or traumatic injury to the teeth,
				  supporting structures (periodontal membrane, gingival, alveolar bone), jaws,
				  and tissue of the oral cavity.
"DIR"
means direct and indirect remuneration.
"Disclosing entity"
means a Medicaid provider
				  (other than an individual practitioner or group of practitioners) or a fiscal
				  agent pursuant to 42 C.F.R.
				  §
										455.101.
"Disenrollment"
means OHCA's removal of an
				  Enrollee from participation in a specific CE or DBM or from participation in
				  the SoonerSelect program.
"DSH"
means disproportionate share hospital.
"Dual eligible individuals"
means individuals
				  eligible for both Medicaid and Medicare.
"Early and Periodic Screening, Diagnostic and Treatment
				  (EPSDT)"
means screening and diagnostic services to determine physical
				  or mental defects in Eligibles or Health Plan Enrollees under age twenty-one
				  (21) and health care, treatment, and other measures to correct or ameliorate
				  any existing defects and/or chronic conditions discovered.
"Electronic Visit Verification (EVV) system"
means an electronic system that documents the time that providers begin and end
				  the delivery of services to Health Plan Enrollees and the location of services.
				  The EVV system shall comply with Section 12006 of the 21 st Century Cures Act
				  and associated CMS requirements.
"Eligible"
means an individual who has been
				  deemed Eligible for the SoonerSelect program but who is not yet enrolled in a
				  CE or DBM.
"Emergency medical condition"
means 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.
"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.
"Encounter data"
means information relating to
				  the receipt of any item(s) or service(s) by an Enrollee under the Contract that
				  is subject to the requirements of
				  42 C.F.R. §§
										438.242 and
				  438.818.
"Enrollee"
means an individual who has been
				  deemed Eligible for Medicaid in the State of Oklahoma, who has been deemed
				  Eligible for enrollment in the SoonerSelect program, and who is currently
				  enrolled in the SoonerSelect program.
"Enrollee handbook"
means a guidebook that
				  explains the SoonerSelect program that the Contactor shall distribute to every
				  Enrollee. It shall be designed to help the Enrollee understand the CE or DBM,
				  the SoonerSelect program and the rights and responsibilities that come with
				  membership in the program.
"Enrollment"
means the OHCA process by which an
				  Eligible becomes an Enrollee with an CE or DBM.
"EOB"
means explanation of benefits.
"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 CE must provide access, including but not
				  limited to neonatal, perinatal, pediatric, trauma and burn services.
"Excluded benefits"
means Medicaid-covered
				  services that are not the responsibility of the CE.
"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.
"Excluded populations"
means populations that
				  are excluded from participation in the SoonerSelect program as specified in the
				  Contract.
"Exploitation"
means an unjust or improper use
				  of the resources of a vulnerable Enrollee for the profit or advantage,
				  pecuniary or otherwise, of a person other than the vulnerable Enrollee through
				  the use of undue influence, coercion, harassment, duress, deception, false
				  representation or false pretense.
"External Quality Review (EQR)"
means the
				  analysis and evaluation by an External Quality Review Organization (EQRO), of
				  aggregated information on quality, timeliness and access to the health care
				  services that the CE or DBM furnishes to Enrollees.
"Family planning services and supplies"
means
				  services and supplies described in § 1905(a)(4)(C) of the Act, including
				  contraceptives and pharmaceuticals for which OHCA claims or could claim federal
				  match at the enhanced rate under § 1905(a)(5) of the Act.
"Federally Qualified Health Center (FQHC)"
or
"Health Centers"
or
"Centers"
means an organization
				  that qualifies for reimbursement under Section 330 of the Public Health Service
				  Act. FQHCs qualify to receive enhanced reimbursements from Medicare and
				  Medicaid, must serve an underserved population or area, offer a sliding fee
				  scale, provide comprehensive services, have an ongoing quality assurance
				  program, and have a governing board of directors.
"Former foster care 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 care"
means planned, goal-directed
				  service that provides twenty-four (24) hour a day substitute temporary care and
				  supportive services in a home environment for children birth to eighteen (18)
				  years of age in OKDHS custody.
"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.
"FPL"
means federal poverty level.
"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 proposed by the CE or DBM to make an authorization
				  decision.
"Grievance and appeal system"
means the
				  processes the CE 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 services
				  outlined in the Oklahoma Medicaid State Plan, the Alternative Benefit Plan, and
				  the 1115 IMD Waiver that are provided, according to contract, by the CE 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.
"Health risk screening"
means a screening tool
				  developed by the contracted entity, and approved by the OHCA, to obtain basic
				  health and demographic information, identify any immediate needs a Health Plan
				  Enrollee may have and assist the contracted entity to assign a risk level for
				  the Health Plan Enrollee to determine the level of care management needed.
"Hospitalization"
means care in a hospital that
				  requires admission as an inpatient and usually requires an overnight stay.
"Implementation"
means the process by which OHCA
				  and the CE 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.
"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 CE or DBM during the initial enrollment period.
"Intermediate sanction(s)"
means the sanctions
				  described in 42 C.F.R §
										438.702, which the OHCA may impose for the
				  contracted entities non-compliance for any of the conditions in
				  42 C.F.R. §
										438.700.
"Juvenile justice involved"
means any person in
				  custody or under the supervision of the Oklahoma Office of Juvenile Affairs
				  (OJA) for whom OJA is required to provide services by law or court order.
"Local Oklahoma provider organization"
means any
				  state provider association, accountable care organization, Certified Community
				  Behavioral Health Clinic, Federally Qualified Health Center, Native American
				  tribe or tribal, association, hospital or health system, academic medical
				  institution, currently practicing licensed provider, or other local Oklahoma
				  provider organization as approved by the Authority.
"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.
"Medical necessity"
or
"medically
				  necessary"
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 CEs, 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-compliance remedy"
means an action taken by
				  OHCA in response to the Contractor's failure to comply with a contract
				  requirement or performance standard.
"Non-participating provider"
means a physician
				  or other provider who has not contracted with or is not employed by the CE or
				  DBM to deliver services under the SoonerSelect program.
"Non-urgent sick visit"
means medical care given
				  for an acute onset of symptoms which is not emergent or urgent, 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.
"OAC"
means Oklahoma Administrative Code.
"ODMHSAS"
means the Oklahoma Department of
				  Mental Health and Substance Abuse Services.
"OHCA"
means the Oklahoma Health Care
				  Authority.
"OJA"
means the Office of Juvenile Affairs.
"OKDHS"
means the Oklahoma Department of Human
				  Services which is also referenced in rules as Department of Human Services
				  (DHS) and Office of Human Services (OHS).
"Open enrollment period"
means the annual period
				  of time, as defined by contract, when Enrollees and Eligibles can enroll in and
				  select an CE or DBM for the SoonerSelect program.
"O.S."
means Oklahoma Statutes.
"OSDE"
means the Oklahoma State Department of
				  Education.
"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 a CE or DBM to provide
				  health care services to Enrollees under the SoonerSelect Medical or Dental
				  program.
"Patient-centered medical home"
or
"PCMH"
means, in this Chapter, the care coordinated delivery
				  system as defined within the contract between OHCA and a CE.
"Pharmacy Benefit Manager"
means a third-party
				  responsible for operating and administering the CE's pharmacy program.
"Post-stabilization care services"
means covered
				  services related to an emergency medical condition that are provided after a
				  Health Plan Enrollee is stabilized to maintain the stabilized condition or
				  under the circumstances described in
				  42 C.F.R. §
										438.114(e), to improve or
				  resolve the Health Plan Enrollee's condition.
"Pregnant women"
means women determined Eligible
				  for SoonerCare under 42
				  C.F.R. §
										435.116.
"Prepaid Ambulatory Health Plan"
or
"PAHP"
means a DBM and/or an entity as per
				  42 C.F.R. §
										438.2 that:
(A) Provides services to Enrollees under
				contract with the state, and on the basis of capitation payments, or other
				payment arrangements that do not use State Plan payment rates;
(B) Does not provide or arrange for, and is
				not otherwise responsible for the provision of any inpatient hospital or
				institutional services for its Enrollees; and
(C) Does not have a comprehensive risk
				contract.
"Prepaid dental plan"
means a contractual
				  arrangement in accordance with 36 O.S. § 6142, whereby any prepaid dental
				  plan organization undertakes to provide payment of dental services directly, or
				  to arrange for prepaid dental services, or to pay or make reimbursement for any
				  dental services not provided for by other insurance.
"Prepaid dental plan organization"
means any
				  person who undertakes to conduct one (1) or more prepaid dental plans providing
				  only dental services in accordance with 36 O.S. § 6142.
"Presumptive eligibility"
means a period of
				  temporary SoonerCare 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
				  entity, on the basis of applicant self-attested income information, to meet the
				  eligibility requirements for a Modified Adjusted Gross Income (MAGI)
				  eligibility group.
"Primary care"
means the provision of
				  integrated, equitable, and accessible health care services by clinicians who
				  are accountable for addressing a large majority of personal health care needs,
				  developing a sustained partnership with patients, and practicing in the context
				  of family and community.
"Primary care dentist"
or
"PCD"
means a dental care professional providing comprehensive dental care for a
				  Dental Health Plan Enrollee.
"Primary care provider"
or
"PCP"
means the following:
(A) Family
				medicine physicians in an outpatient setting when practicing general primary
				care;
(B) General pediatric
				physicians and adolescent medicine physicians in an outpatient setting when
				practicing general primary care;
(C) Geriatric medicine physicians in an
				outpatient setting when practicing general primary care;
(D) Internal medicine physicians in an
				outpatient setting when practicing general primary care (excludes internists
				who subspecialize in areas such as cardiology, oncology, and other common
				internal medicine subspecialties beyond the scope of general primary care);
(E) Obstetrics and gynecology
				physicians in an outpatient setting when practicing general primary care;
(F) Providers such as nurse
				practitioners and physicians' assistants in an outpatient setting when
				practicing general primary care; or
(G) Behavioral health providers, including
				psychiatrists, providing mental health and substance use disorder services when
				integrated into a primary care setting.
"Prior authorization"
or
"PA"
means
				  a requirement that an Enrollee, through the Enrollee's provider, obtain the CEs
				  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.
"Protected health information"
or
"PHI"
means information considered to be individually identifiable
				  health information, per 42
				  C.F.R.§
											160.103.
"Provider"
means a health care services provider
				  licensed or certified in this State.
"Provider agreement"
means an agreement between
				  the CE or DBM and a participating provider that describes the conditions under
				  which the participating provider agrees to furnish covered health care services
				  to Enrollees.
"Provider-led entity"
means an organization or
				  entity that meets the criteria of at least one (1) of the following:
(A) A majority of the entity's ownership is
				held by Medicaid providers in this state or is held by an entity that directly
				or indirectly owns or is under common ownership with Medicaid providers in the
				state; or
(B) A majority of the
				entity's governing body is composed of individuals who:
(i) Have experience serving Medicaid members
				and:
(I) Are licensed in the state as
				physicians, physician assistants, nurse practitioners, certified
				nurse-midwives, or certified registered nurse anesthetists;
(II) At least one (1) board member is a
				licensed behavioral health provider; or
(III) Are employed by a hospital or other
				medical facility licensed by the state and operating in the state or an
				inpatient or outpatient mental health or substance abuse treatment facility or
				program licensed or certified by the state and operating in the state.