Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-10 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"Adverse decision" means a utilization review determination
					 by the utilization review entity that a health service rendered or proposed to
					 be rendered was not or is not medically necessary, when such determination may
					 result in noncoverage of the health service or health services. When the
					 policy, contract, plan, certificate, or evidence of coverage includes coverage
					 for prescription drugs and the health service rendered or proposed to be
					 rendered is a prescription for the alleviation of cancer pain, any adverse
					 decision shall be made within 24 hours of the request for coverage.
"Appeal" means a formal request by a covered person or a
					 provider on behalf of a covered person for reconsideration of a decision, such
					 as a final adverse decision, a benefit payment, a denial of coverage, or a
					 reimbursement for service.
"Basic health care services" means those health care
					 services, as applicable to the type of managed care health insurance plan,
					 described in §
										38.2-5800 of the Code
					 of Virginia which are required to be provided, arranged, paid for, or
					 reimbursed by the managed care health insurance plan licensee for its covered
					 persons.
"Board" means the Board of Health.
"Bureau of Insurance" means the State Corporation
					 Commission acting pursuant to Title 38.2 of the Code of Virginia.
"Center" means the Center for Quality Health Care Services
					 and Consumer Protection of the Virginia Department of Health.
"Certificate" means a certificate of quality
					 assurance.
"Complaint" means a written communication from a covered
					 person primarily expressing a grievance. A complaint may pertain to the
					 availability, delivery, or quality of health care services including claims
					 payments, the handling or reimbursement for such services, or any other matter
					 pertaining to the covered person's contractual relationship with the
					 MCHIP.
"Covered person" means an individual residing in the
					 Commonwealth, whether a subscriber, policyholder, enrollee, or member, of a
					 managed care health insurance plan (MCHIP), who is entitled to health services
					 or benefits provided, arranged for, paid for, or reimbursed pursuant to an
					 MCHIP.
"Delegated service entity" means the entity with which an
					 MCHIP licensee contracts to provide one or more of the services listed in
					 12VAC5-408-320
					 A for one or more of its MCHIPs, pursuant to and in accordance with the
					 provisions of Part VI (12VAC5-408-320
					 et seq.) of this chapter, inclusive.
"Department" means the Virginia Department of
					 Health.
"Emergency services" means those health care services as
					 defined in §
										38.2-3438 of the Code
					 of Virginia.
"Evidence of coverage" means any certificate, individual or
					 group agreement or contract, or identification card or related document issued
					 in conjunction with the certificate, agreement or contract, issued to a covered
					 person setting out the coverage and other rights to which a covered person is
					 entitled.
"Final adverse decision" means a utilization review
					 determination made by a physician advisor or peer of the treating health care
					 provider in a reconsideration of an adverse decision, and upon which a provider
					 or patient may base an appeal.
"Health care data reporting system" means the state
					 contracted integrated system for the collection and analysis of data used by
					 consumers, employers, providers, and purchasers of health care to continuously
					 assess and improve the quality of health care in the Commonwealth.
"Health care provider" or "provider" has the same meaning
					 ascribed to the term in §
										32.1-127.1:03B
					 of the Code of Virginia.
"Health care services" means services as defined in §
										38.2-3438 of the Code
					 of Virginia.
"Health carrier" means an entity as defined in §
										38.2-3438 of the Code
					 of Virginia.
"Managed care health insurance plan" or "MCHIP" means an
					 arrangement for the delivery of health care in which a health carrier, as
					 defined in §
										38.2-5800 of the Code
					 of Virginia, undertakes to provide, arrange for, pay for, or reimburse any of
					 the costs of health care services for a covered person on a prepaid or insured
					 basis which (i) contains one or more incentive arrangements, including any
					 credentialing requirements intended to influence the cost or level of health
					 care services between the health carrier and one or more providers with respect
					 to the delivery of health care services and (ii) requires or creates benefit
					 payment differential incentives for covered persons to use providers that are
					 directly or indirectly managed, owned, under contract with or employed by the
					 health carrier. 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 managed care
					 health insurance plans. 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, owned, 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.
"Managed care health insurance plan licensee" or "MCHIP
					 licensee" means a health carrier subject to licensure by the Bureau of
					 Insurance and to quality assurance certification by the department under Title
					 38.2 of the Code of Virginia who is responsible for a managed care health
					 insurance plan in accordance with Chapter 58 (§
										38.2-5800 et seq.) of
					 Title 38.2 of the Code of Virginia.
"Managed care plan" means a health benefit plan, as defined
					 in § 38.2-3407.10:1 of the Code of Virginia, that requires a covered
					 person to use, or creates incentives, including financial incentives, for a
					 covered person to use health care providers managed, owned, under contract
					 with, or employed by the MCHIP licensee.
"Material" means that which has an effective influence or
					 bearing on, or is pertinent to, the issue in question.
"Medical necessity" or "medically necessary" means
					 appropriate and necessary health care services which are rendered for any
					 condition which, according to generally accepted principles of good medical
					 practice, requires the diagnosis or direct care and treatment of an illness,
					 injury, or pregnancy-related condition, and are not provided only as a
					 convenience.
"Nationally recognized accrediting body" means an
					 organization that sets national standards specifically governing healthcare
					 quality assurance processes, utilization review, provider credentialing, as
					 well as other areas covered by this chapter and provides accreditation to
					 managed care health insurance plans pursuant to national standards. The
					 following entities shall be considered nationally recognized accrediting
					 bodies:
1. The American Accreditation HealthCare
					 Commission/URAC;
2. The National Committee for Quality Assurance
					 (NCQA);
3. The Joint Commission on Accreditation of Healthcare
					 Organizations, (JCAHO); and
4. Other nationally recognized accrediting bodies with
					 national standards as described above that are accepted by the department.
"Network" means a group of providers as defined in §
										38.2-3438 of the Code
					 of Virginia.
"New provider applicant" means a provider that has
					 submitted a completed credentialing application to an MCHIP licensee.
"Participating provider" means a provider that is managed,
					 under contract with, or employed by an MCHIP licensee and who has agreed to
					 provide health care services to covered persons with an expectation of
					 receiving payments, other than coinsurance, copayments, or deductibles,
					 directly or indirectly from the MCHIP licensee.
"Person" means any individual, aggregate of individuals,
					 association, business, company, corporation, joint-stock company, Lloyds type
					 of organization, other organization, partnership, receiver, reciprocal or
					 inter-insurance exchange, trustee or society.
"Plan of correction" means an MCHIP'S written plan that
					 outlines the action the MCHIP will take to address compliance issues identified
					 during an administrative review or on-site examination conducted by the
					 department.
"Preferred provider organization" or "PPO" means an
					 arrangement in which a health carrier, as defined in §
										38.2-5800 of the Code
					 of Virginia, undertakes to provide, arrange for, pay for, or reimburse any of
					 the costs of health care services, on an insured basis, which creates
					 incentives, including financial incentives, for a covered person to use health
					 care providers directly or indirectly managed, owned, under contract with, or
					 employed by the health carrier, but shall not include a health maintenance
					 organization as defined in §
										38.2-4300 of the Code
					 of Virginia.
"Quality assurance program" means the systems, standards
					 and processes including, but not limited to, reasonable and adequate systems to
					 assess, measure, and improve the health status of covered persons, necessary to
					 obtain a certificate of quality assurance from the department in accordance
					 with this chapter and in accordance with §
										32.1-137.2C
					 of the Code of Virginia.
"Service area" means a geographic area as defined in §
										38.2-5800 of the Code
					 of Virginia.
"Timely" means the provision of services so as not to
					 impair or jeopardize the integrity of the covered persons' diagnosis or
					 outcomes of illness.
"Treating health care provider" means a licensed health
					 care provider who renders or proposes to render health care services to a
					 covered person.
"Utilization review" means a system for reviewing the
					 necessity, appropriateness, and efficiency of hospital, medical or other health
					 care services rendered or proposed to be rendered to a patient or group of
					 patients for the purpose of determining whether such services should be covered
					 or provided by an insurer, health services plan, managed care health insurance
					 plan licensee, or other entity or person. For purposes of this chapter,
					 "utilization review" shall include, but not be limited to, preadmission,
					 concurrent and retrospective medical necessity determination, and review
					 related to the appropriateness of the site at which services were or are to be
					 delivered. "Utilization review" shall not include (i) review of issues
					 concerning insurance contract coverage or contractual restrictions on
					 facilities to be used for the provision of services, (ii) any review of patient
					 information by an employee of or consultant to any licensed hospital for
					 patients of such hospital, or (iii) any determination by an insurer as to the
					 reasonableness and necessity of services for the treatment and care of an
					 injury suffered by an insured for which reimbursement is claimed under a
					 contract of insurance covering any classes of insurance defined in §§
										38.2-117
					 through
					 38.2-119,
					 38.2-124 through
					 38.2-126,
					 38.2-130
					 through
					 38.2-132
					 and
					 38.2-134
					 of the Code of Virginia.
"Utilization review entity" means a person or entity
					 performing utilization review.
"Utilization review plan" means a written procedure for
					 performing a utilization review.
Statutory Authority: §§
												32.1-12
						and
						32.1-137.3 of the
						Code of Virginia.