Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-360 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this part shall
					 have the following meanings unless the context clearly indicates otherwise. All
					 other words and terms used in this part shall comply with the definitions in
					 the contract and those identified
					 42
					 CFR 438.2:
"Adverse benefit determination" means, consistent with
					 42 CFR
					 438.400, (i) the denial or limited
					 authorization of a requested service; (ii) the failure to take action or timely
					 take action on a request for service; (iii) the reduction, suspension, or
					 termination of a previously authorized service; (iv) the denial in whole or in
					 part of a payment for a covered service; (v) the failure to provide services
					 within the timeframes required by the state, or for a resident of a rural
					 exception area with only one MCO, the denial of a member's request to exercise
					 his right under
					 42 CFR
					 438.52(b)(2)(ii) to obtain
					 services outside of the network; (vi) the denial of a member's request to
					 dispute a financial liability; or (vii) the failure of an MCO to act within the
					 timeframes provided in
					 42 CFR
					 438.408(b).
"Appeal" when applicable to a member means a request to
					 DMAS to review an MCO's internal appeal decision to uphold the contractor's
					 adverse benefit determination. For members, an appeal may only be requested
					 after exhaustion of the MCO's one step internal appeal process. Member appeals
					 to DMAS will be conducted in accordance with regulations at 42 CFR 431 Subpart
					 E and
					 12VAC30-110-10
					 through
					 12VAC30-110-370.
"Appeal" when applicable to an appeal by a provider means a
					 request to DMAS to review an MCO's reconsideration decision. For providers, an
					 appeal may only be requested after exhaustion of the MCO's reconsideration
					 process. Provider appeals to DMAS will be conducted in accordance with the
					 requirements set forth in §
										2.2-4000 et
					 seq. of the Code of Virginia and
					 12VAC30-20-500 et
					 seq.
"Covered services" means Medicaid services as defined in
					 the State Plan for Medical Assistance.
"Day" means calendar day unless otherwise stated.
"Disenrollment" means the process of changing enrollment
					 from one managed care organization (MCO) plan to another MCO, if
					 applicable.
"DMAS" means the Department of Medical Assistance
					 Services.
"Eligible person" means any person eligible for Virginia
					 Medicaid in accordance with the State Plan for Medical Assistance under Title
					 XIX of the Social Security Act.
"Emergency services" means those health care services that
					 are rendered by participating or nonparticipating providers after the sudden
					 onset of a medical condition 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 (i) placing the client's health in
					 serious jeopardy; (ii) with respect to a pregnant woman, placing the health of
					 the woman or her unborn child in serious jeopardy; (iii) serious impairment to
					 bodily functions; or (iv) serious dysfunction of any bodily organ or
					 part.
"Exclude" means the removal of a member from the Medallion
					 mandatory managed care program on a temporary or permanent basis.
"External quality review organization" or "EQRO" means an
					 organization that meets the competence and independence requirements set forth
					 in
					 42 CFR
					 438.354 and performs external quality
					 reviews, other external quality review related activities as set forth in
					 42 CFR
					 438.358, or both.
"Grievance" means, in accordance with
					 42 CFR
					 438.400, an expression of dissatisfaction
					 about any matter other than an "adverse benefit determination." Possible
					 subjects for grievances include the quality of care or services provided;
					 aspects of interpersonal relationships, such as rudeness of a provider or
					 employee; or failure to respect the member's rights.
"Health care professional" means a provider as defined in
					 42
					 CFR 438.2.
"Individual" means a person who is eligible for Medicaid
					 who is not yet undergoing enrollment for mandatory managed care and who is not
					 enrolled in a mandatory managed care organization.
"Internal appeal" means a request to the MCO by a member or
					 by a member's authorized representative or provider acting on behalf of the
					 member and with the member's written consent for review of a contractor's
					 adverse benefit determination, as defined in
					 42 CFR
					 438.400. The internal appeal is the only
					 level of appeal with the MCO and must be exhausted by a member or deemed
					 exhausted according to
					 42 CFR
					 438.408(c)(3) before the
					 member may initiate a state fair hearing with DMAS.
"Managed care organization" or "MCO" means an organization
					 that offers managed care health insurance plans (MCHIP), as defined by §
										38.2-5800 of the Code
					 of Virginia. Any health maintenance organization as defined in §
										38.2-4300 of the Code
					 of Virginia or health carrier that offers preferred provider contracts or
					 policies as defined in §
										38.2-3407
					 of the Code of Virginia or preferred provider subscription contracts as defined
					 in §
										38.2-4209
					 of the Code of Virginia shall be deemed to be offering one or more MCHIPs. For
					 the purposes of this definition, the prohibition of balance billing by a
					 provider shall not be deemed a benefit payment differential incentive for
					 covered persons to use providers who are directly or indirectly managed by,
					 owned by, under contract with, or employed by the health carrier. A single
					 managed care health insurance plan may encompass multiple products and multiple
					 types of benefit payment differentials; however, a single managed care health
					 insurance plan shall encompass only one provider network or set of provider
					 networks.
Additionally, and in accordance with
					 42
					 CFR 438.2, "managed care organization" or
					 "MCO" means an entity that has qualified to provide the services covered in the
					 Medallion program to qualifying Medallion members as accessible in terms of
					 timeliness, amount, duration, and scope as those services are to other Medicaid
					 members within the area served, and that meets the solvency standards of
					 42 CFR
					 438.116.
"Mandatory managed care program" means the same as set
					 forth in
					 42 CFR 438.54(b) and
					 (d).
"Member" means a person eligible for Medicaid or Family
					 Access to Medical Insurance Security who has been assigned to a Medicaid
					 MCO.
"Network provider" means doctors, hospitals, or other
					 health care providers who participate or contract with an MCO contractor and as
					 a result agree to accept a mutually agreed upon sum or fee schedule as payment
					 in full for covered services that are rendered to eligible participants.
"Newborn enrollment period" means the period from the
					 child's date of birth plus the next two calendar months.
"PCP of record" means a primary care physician of record
					 with whom the recipient has an established history, and such history is
					 documented in the individual's records.
"Reconsideration" means a provider's request to the MCO for
					 review of an adverse benefit determination. The MCO's reconsideration decision
					 is a prerequisite to a provider's filing of an appeal, as provided for in
					 12VAC30-20-500
					 through
					 12VAC30-20-560, to
					 DMAS Appeals Division.
"Rural exception" means a rural area designated in the
					 § 1915(b) managed care waiver, pursuant to § 1932(a)(3)(B) of the
					 Social Security Act and
					 42 CFR
					 438.52(b) and recognized by
					 the Centers for Medicare and Medicaid Services, wherein qualifying mandatory
					 managed care members are mandated to enroll in the one available contracted
					 MCO.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.