Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter I - CONTRACTUAL ARRANGEMENTS BETWEEN HMOs AND IDSs-STATEMENT OF POLICY › GENERAL PROVISIONS › Section 301.301 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
						subchapter, have the following meanings, unless the context clearly indicates
						otherwise:
Contract
-An arrangement between an HMO
						and a risk-bearing IDS, whereby the IDS is obligated to perform marketing,
						enrollment, administrative or similar functions. Administrative functions do
						not include quality assurance, utilization review, credentialing, provider
						relations or related functions.
Examination Law
-Sections 901-1013 of The
						Insurance Company Law of 1921 (40 P. S. §§
												323.1-324.13).
HMO-Health Maintenance Organization
-An
						organized system which combines the delivery and financing of health care and
						the provision of basic health services to voluntarily enrolled members for a
						fixed prepaid fee, and is required to obtain a certificate of authority in
						accordance with applicable statutes and regulations (See sections 4 and 5.1 of
						the act (40 P. S. §§
												1554
						and 1555.1) and §§
											301.41 and
						301.42 (relating to prohibition
						against uncertified HMOs, and content of application for certificate of
						authority).
IDS-Integrated Delivery System
-A
						partnership, association, corporation or other legal entity which enters into a
						contractual arrangement with an HMO; employs or has contracts with providers
						(participating providers); and agrees under its arrangements with an HMO, to
						provide or arrange for the provision of a defined set of health care services
						to HMO members covered under an HMO benefits contract principally through its
						participating providers, assumes under the arrangements some responsibility for
						conduct, in conjunction with the HMO and under compliance monitoring of the
						HMO, of quality assurance, utilization review, credentialing, provider
						relations, or related functions, may perform claims processing and other
						functions and which assumes to some extent, through capitation reimbursement or
						other risk-sharing arrangements, the financial risk for provision of these
						services to HMO members.
Provider
-A "health care facility" or
						"health care provider" as those terms are defined under section 802(a) of the
						Health Care Facilities Act (35 P. S. §
												448.802(a)), a mental health
						facility licensed by the Department of Public Welfare, or an individual
						licensed by the Commonwealth to practice a profession involved in the healing
						arts. The term includes hospitals, mental health treatment facilities, drug and
						alcohol treatment facilities, physicians, dentists, podiatrists, psychologists,
						nurses, physician assistants, certified registered nurse practitioners,
						physical therapists, chiropractors, optometrists and pharmacists.
Risk
-The possibility of financial loss
						associated with contracts to perform a defined set of health care services for
						a predetermined portion of premium dollars.