West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-56 - Quality Assurance Standards For Prepaid Limited Health Service Organizations › Section 114-56-2 - 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 or member's needs.
2.3. "Clinician" means a state-recognized provider
				including, but not limited to, physicians, psychologists and psychiatrists who
				specialize in clinical studies or practice.
2.4. "Commissioner" means the West Virginia
				Insurance Commissioner.
2.5.
				"Coordinating provider" means the provider of a particular limited health service
				who is chosen or designated for each subscriber and who will be responsible for
				coordinating the provision of that particular limited health service to the
				subscriber, including necessary referrals to other providers of the limited health
				service: Provided, That if a subscriber is also enrolled in a health maintenance
				organization, the coordinating provider shall send a written report at least
				annually to the subscriber's primary care physician, as defined in article
				twenty-five-a of this chapter, describing the limited health service provided to the
				subscriber: Provided, however, That the coordinating provider may disclose data or
				information only as permitted under W. Va. Code '33-25D-12.
2.6. "Credentialing" means the process by which a
				prepaid limited health service organization authorizes, contracts with or employs
				providers, who are licensed to practice independently, to provide services to its
				members.
2.7. "DEA" means Drug
				Enforcement Administration, the federal agency that issues licenses to prescribe and
				dispense scheduled drugs.
2.8.
				"Delegation" or "delegated" means the formal process by which a prepaid limited
				health service organization gives a contractor the authority to perform certain
				functions on its behalf, such as credentialing, utilization review and quality
				assurance. A prepaid limited health service organization can delegate the authority
				to perform a function but cannot delegate the responsibility for assuring the
				function is performed properly.
2.9.
				"Governing body" means an individual, group or agency with the ultimate authority
				and responsibility for the overall operation of the organization.
2.10. "Limited health service" and "health care
				service" means mental or behavioral health services (including mental illness,
				mental retardation, developmental disabilities, substance abuse, and chemical
				dependency), together with any services or goods included in the furnishing to any
				individual of a limited health service. "Limited health services" does not include
				inpatient services, hospital surgical services or emergency services except as such
				services are provided incident to and directly related to a limited health service
				set forth in this subsection.
2.11.
				"Member," "subscriber" or "enrollee" means an individual who has been voluntarily
				enrolled in a prepaid limited health service organization, including individuals on
				whose behalf a contractual arrangement has been entered into with a prepaid limited
				health service organization to receive limited health services.
2.12. "Oversight" means the monitoring and
				direction of a set of activities by individuals responsible for the execution of the
				activities resulting in the achievement of desired outcomes.
2.13. "Practice guidelines" or "protocols" means
				systematically developed statements to assist patient and provider decisions about
				appropriate health care for specific clinical circumstances. Practice guidelines are
				usually based on such authoritative sources as clinical literature and expert
				consensus.
2.14. "Preauthorization"
				means prior assessment that proposed limited health services are covered by the
				member's benefit plan and are appropriate for a particular member.
2.15. "Prepaid limited health service
				organization" means a public or private organization which provides, or otherwise
				makes available to enrollees, limited health services and which:
a. Receives premiums for the provision of limited
				health services to enrollees on a prepaid per capita or prepaid aggregate fixed sum
				basis, excluding copayments;
b. Provides
				limited health services primarily:
1. Directly
				through an exclusive panel of physicians or other providers who are employees or
				partners of the organization;
2. Through
				arrangements with individual physicians or other providers or one or more groups of
				physicians or other providers organized on a group practice or individual practice
				arrangement; or
3. Some combination of
				paragraphs 1 and 2 of this subdivision.