Ariz. Admin. Code § R20-6-1902 - Definitions
In addition to the definitions provided in A.R.S. § 20-1051, the following terms apply to this Article:
1. "Access" or
"accessibility" means the extent to which an enrollee can obtain timely covered
services from a contracted provider at the appropriate level of care, and
appropriate location.
2. "Adult"
means an enrollee in the age group the HCSO has designated for an
adult.
3. "Adult PCP" means a
primary care provider practicing in any specialty the HCSO designates as adult
primary care.
4. "Ancillary
provider" means a provider of laboratory, radiology, pharmacy or rehabilitative
services, physical therapy, occupational therapy, or speech therapy, home
health services, dialysis, and durable medical equipment or medical supplies
dispensed by order or prescription of a provider with the appropriate
prescribing authority.
5.
"Available" or "availability" means the extent to which the plan has contracted
providers of the appropriate type and numbers at geographic locations to afford
members access to timely covered services.
6. "Chief executive officer" or "CEO" means
the person who has the authority and responsibility for the operation of the
health care services organization according to applicable legal requirements
and policies approved by the governing authority.
7. "Child" means an enrollee in the age group
the HCSO has designated for children.
8. "Contracted" means a provider has a
current written agreement or an employment arrangement with an HCSO to provide
covered services to an enrollee, or a current written agreement or an
employment arrangement with a contracted provider to provide covered services
to an enrollee.
9. "Covered" or
"covered services" means the health care services described as covered benefits
in the HCSO's evidence of coverage.
10. "Day" means calendar day unless specified
otherwise.
11. "Department" means
the Department of Insurance and Financial Institutions.
12. "Director" has the meaning stated at
A.R.S. §
20-102.
13. "Effective process" means written
policies and procedures that:
a. Outline the
steps that the HCSO implements and consistently follows internally,
b. The HCSO subjects to internal quality
improvement, and
c. The HCSO
communicates to providers when established or changed.
14. "Emergency services" has the meaning
stated at A.R.S. §
20-2801(3).
"Enrollee" means an individual who
is enrolled in a health plan operated by an HCSO.
15. "Facility" means an institution that is
licensed or authorized to furnish health care services in this state, including
general hospitals, special hospitals, residential treatment centers,
residential rehabilitation centers, skilled nursing facilities, urgent care
centers, and ambulatory surgical treatment centers.
16. "Governing authority" means a person or
body such as a board of trustees or board of directors in whom the ultimate
authority and responsibility for the direction of the HCSO is vested.
17. "HCSO" means a health care services
organization.
"Health care services" has the
meaning in A.R.S. § 20-1051(6) .
18. "High profile" means one of no fewer than
four specialties designated by the HCSO, and does not include
obstetrics-gynecology. An HCSO may designate a specialty as high profile on the
basis of high volume or other basis the HCSO reasonably determines is directly
related to providing covered services to a member.
19. "Hospital" means a facility that provides
inpatient care, medical services, and continuous nursing services for the
diagnosis and treatment of patients.
20. "Inpatient care" means the covered
services that an enrollee who is admitted to a hospital receives for at least
24 consecutive hours.
21.
"Inpatient emergency care" means covered services that would be emergency
services if provided in a licensed hospital emergency facility.
22. "License" means documented authorization
issued by the appropriate state of Arizona agency to operate a facility in
Arizona, or to practice a health care profession in Arizona.
23. "Medically necessary" has the meaning set
forth in the HCSO's evidence of coverage.
24. "Network" means the group of providers
contracted with an HCSO to provide covered services to an enrollee covered
under the HCSO's health benefit plan.
25. "Network exception" means an enrollee
receives covered services from a non-contracted provider either:
a. Because there is no contracted provider
accessible or available that can provide the enrollee timely covered services,
or
b. For any reason the HCSO
determines it is in the enrollee's best interests to receive care from a
non-contracted provider.
26. "Non-contracted" means a provider that
does not have a contract with an HCSO to provide services to an
enrollee.
27. "Normal business
hours" means 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding state or
national holidays.
28. "Outpatient
care" means covered services that an enrollee who is not an inpatient
receives.
29. "Pediatric primary
care provider" means a physician or practitioner practicing in any specialty
the HCSO designates as pediatric primary care.
30. "Physician" means a licensed doctor of
allopathic, chiropractic, optometric, osteopathic, or podiatric
medicine.
31. "Practitioner" means
any individual other than a physician who is licensed to furnish health care
services, including behavioral health care services, in this state.
32. "Preventive care" means health
maintenance care the HCSO provides or arranges to prevent illness and to
improve the general health of an enrollee, including:
a. Immunizations,
b. Health education,
c. Health evaluation and follow-up,
d. Early disease detection,
e. Screening tests appropriate for a person's
age and gender, and
f. Periodic
health care examinations.
33. "Primary care" means any specialty the
HCSO designates as primary care.
34. "Primary care physician" or "PCP" means a
physician or practitioner practicing in a specialty the HCSO designates as
primary care.
"Provider" means any physician,
practitioner, ancillary provider, or facility.
35. "Quality improvement" means an HCSO's
system for assessing and improving the level of performance of key process and
outcomes.
36. "Routine care" means
covered primary care for an enrollee's non-urgent, symptomatic
condition.
37. "Rural" means a zip
code area with fewer than 1,000 persons per square mile as calculated annually
by a population data gathering service designated by the Director.
38. "Service area" means any geographic area
designated by any HCSO and approved by the Director under A.R.S. §
20-1053(A)(11).
39.
"Specialty
care provider" or "SCP" means a physician or practitioner who has education,
training, or qualifications in a specialty, other than primary care, beyond the
education or qualifications required for the license. "Special
hospital" means a hospital that is licensed to provide hospital services within
a specific area of medicine, or limits patient admission according to age,
gender, type of disease, or medical condition.
40. "Specialty" or "specialty care" means a
specific area of medicine practiced by a physician or practitioner who has
education, training, or qualifications in that specific area of medicine in
addition to the education or qualifications required for the physician's or
practitioner's license.
41.
"Special hospital" means a hospital that is licensed
to provide hospital services within a specific area of medicine, or limits
patient admission according to age, gender, type of disease, or medical
condition. "Specialty care provider" or "SCP" means a physician or
practitioner who has education, training, or qualifications in a specialty,
other than primary care, beyond the education or qualifications required for
the license.
42. "Suburban area"
means any zip code area with 1,000-3,000 persons per square mile, as calculated
annually by a population data gathering service designated by the
Director.
43. "Telemedicine"
means diagnostic, consultation, and treatment
services that occur in the physical presence of an enrollee on a real-time
basis through interactive audio, video, or data communication. has the
same meaning as "telehealth" found at A.R.S. §
20-1057(G).
44. "Timely" means services are provided at
the time when medically necessary.
45. "Travel expenses" has the meaning set
forth in writing by an HCSO.
46.
"Urban area" means a zip code with more than 3,000 persons per square mile as
calculated annually by a population data gathering service designated by the
Director.
47. "Urgent care" means
unscheduled services for an enrollee's condition that requires medical
attention not amenable to scheduling in order to avoid a serious risk of
harm.
Notes
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