Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter F - GENERAL › Section 9.602 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Act
-The Insurance Company Law of 1921
					 (40
					 P. S. §§
											361-991.2361).
Act 68
-The act of June 17, 1998 (P. L.
					 464, No. 68) (40 P. S. §§
											991.2001-991.2361) which added Articles XX
					 and XXI of the act.
Active clinical practice
-The practice of
					 clinical medicine by a health care provider for an average of not less than 20
					 hours per week.
Ancillary service plan
-
(i) An individual or group health insurance
				  plan, subscriber contract or certificate, that provides exclusive coverage for
				  dental services or vision services.
(ii) The term also includes Medicare
				  Supplement Policies subject to section 1882 of the Social Security Act
				  (42 U.S.C.A. §
											1395ss) and the Civilian Health and Medical
				  Program of the Uniformed Services (CHAMPUS) supplement.
Ancillary services
-A health care service
					 that is not directly available to enrollees but is provided as a consequence of
					 another covered health care service, such as radiology, pathology, laboratory
					 and anesthesiology.
Article XXI
-Sections 2101-2193 of the act
					 (40
					 P. S. §§
											991.2101-991.2193)
					 relating to health care accountability and protection.
Basic health services
or
basic
					 health care services
-The health care services in §
										9.651 (relating to HMO provision
					 and coverage of basic health care services to enrollees).
CRE-Certified utilization review entity
-An
					 entity certified under this chapter to perform UR on behalf of a plan.
Certificate of authority
-The document
					 issued jointly by the Secretary and the Commissioner that permits a corporation
					 to establish, maintain and operate an HMO.
Commissioner
-The Insurance Commissioner of
					 the Commonwealth.
Complaint
-
(i) A dispute or objection by an enrollee
				  regarding a participating health care provider, or the coverage (including
				  contract exclusions and non-covered benefits), operations or management
				  policies of a managed care plan, that has not been resolved by the managed care
				  plan and has been filed with the plan or the Department or the Insurance
				  Department.
(ii) The term does not
				  include a grievance.
Department
-The Department of Health of the
					 Commonwealth.
Drug formulary
-A listing of a managed care
					 plan's preferred therapeutic drugs.
EQRO-External quality review
					 organization
-An entity approved by the Department to conduct an
					 external quality assurance assessment of an HMO.
Emergency service
-
(i) A health care service provided to an
				  enrollee after the sudden onset of a medical condition that manifests itself by
				  acute symptoms of sufficient severity or severe pain such 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 one
				  or more of the following:
(A) Placing the
				  health of the enrollee or, with respect to a pregnant woman, the health of the
				  woman or her unborn child in serious jeopardy.
(B) Serious impairment to bodily
				  functions.
(C) Serious dysfunction
				  of any bodily organ or part.