West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Accountability"
				means the responsibility of a department or individual for achieving defined
				goals.
2.2. "Appropriateness" means the
				extent to which a particular procedure, treatment, test or service is clearly
				indicated, not excessive, adequate in quantity and provided in the setting best
				suited to the patient's/member's needs.
2.3. "Commissioner" means the West Virginia
				Insurance Commissioner.
2.4. "Clinician"
				means a state-recognized provider including but not limited to physicians,
				psychologists and psychiatrists who specialize in clinical studies or
				practice.
2.5. "Credentialing" means the
				process by which a health maintenance organization authorizes, contracts with or
				employs clinicians, who are licensed to practice independently, to provide services
				to its members.
2.6 "DEA" means Drug
				Enforcement Administration, the Federal agency that issues licenses to prescribe and
				dispense scheduled drugs.
2.7.
				"Delegation" or "delegated" means the formal process by which a health maintenance
				organization gives a contractor the authority to perform certain functions on its
				behalf, such as credentialing, utilization review and quality assurance. A health
				maintenance organization can delegate the authority to perform a function but cannot
				delegate the responsibility for assuring the function is performed
				properly.
2.8. "Governing body" means an
				individual, group or agency with the ultimate authority and responsibility for the
				overall operation of the organization.
2.9 "Health care services" means any services or
				goods included in the furnishing to any individual of medical, mental or dental
				care, or hospitalization, osteopathic services, chiropractic services, podiatric
				services, home health, health education, or rehabilitation, as well as the
				furnishing to any person of any and all other services or goods for the purpose of
				preventing, alleviating, curing or healing human illness or injury.
2.10. "Health maintenance organization" or "HMO"
				means a public or private organization which provides, or otherwise makes available
				to enrollees, health care services, including at a minimum basic health care
				services, which:
a. Receives premiums for the
				provision of basic health care services to enrollees on a prepaid per capita or
				prepaid aggregate fixed sum basis, excluding copayments;
b. Primarily provides physicians' services:
1. Directly through physicians who are either
				employees or partners of the organization;
2. Through arrangements with individual physicians
				or one or more groups of physicians organized on a group practice or individual
				practice arrangement; or
3. Through some
				combination of paragraphs one and two of this subdivision;
c. Assures the availability, accessibility and
				quality including appropriate utilization of the health care services that it
				provides or makes available through clearly identifiable focal points of legal and
				administrative responsibility; and
d.
				Offers services through an organized delivery system, in which a primary care
				physician is designated for each subscriber upon enrollment. The primary care
				physician is responsible for coordinating the health care of the subscriber and is
				responsible for referring the subscriber to other providers when necessary:
				Provided, that when dental care is provided by the health maintenance organization
				the dentist selected by the subscriber from the list provided by the health
				maintenance organization shall coordinate the covered dental care of the subscriber,
				as approved by the primary care physician or the health maintenance
				organization.