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 CE or DBM or according to managed care law,
				  regulations, and contracts.
"C.F.R."
means the Code of Federal
				  Regulations.
"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
				  state-wide 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.
"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".
"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 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
				  contracted entity employee or contracted provider, or failure to respect the
				  Enrollee's rights regardless of whether remedial action is requested. A
				  grievance includes a Enrollee's right to dispute an extension of time to make
				  an authorization decision when proposed by the Contractor.
"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 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".
"Member"
means an individual eligible for
				  Medicaid in the State of Oklahoma, eligible for a managed care program, and
				  enrolled in a CE or DBM . "Member" is synonymous with "Enrollee".
"OAC"
means the Oklahoma Administrative
				  Code.
"OHCA"
means the Oklahoma Health Care
				  Authority.
"O.S."
means the Oklahoma Statutes.
"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"
or
"PA"
means
				  a requirement that a member, through a provider, obtain the CE or DBM 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.