As used in Chapter 5160-26 of the Administrative Code:
(A) "Abuse" means provider practices that are
inconsistent with sound fiscal, business, or medical practices, and result in
an unnecessary cost to the medicaid program, or in reimbursement for services
that are not medically necessary or that fail to meet professionally recognized
standards for health care. It also includes recipient practices that result in
unnecessary cost to the medicaid program.
(B) "Advance directive" means written
instructions such as a living will or durable power of attorney for health care
relating to the provision of health care when an adult is
incapacitated.
(C)
"Adverse benefit determination" is a managed care
entity's (MCE's):
(1)
Denial or limited authorization of a requested service,
including determinations based on the type or level of service, requirements
for medical necessity, appropriateness, setting, or effectiveness of a covered
benefit;
(2)
Reduction, suspension, or termination of services prior
to the member receiving the services previously authorized by the
MCE;
(3)
Failure to provide services in a timely manner as
specified in rule
5160-26-03.1 of the
Administrative Code;
(4)
Failure to act within the resolution time frames
specified in rule
5160-26-08.4 of the
Administrative Code;
(5)
Denial of a member's request to dispute a financial
liability, including cost sharing, copayments, premiums, deductibles,
coinsurance and other member financial liabilities, if applicable;
or
(6)
Denial, in whole or part, of payment for a service. A
denial, in whole or in part, of a payment for a service solely because the
claim does not meet the definition of a "clean claim" as defined in
42 C.F.R.
447.45(b) (October 1, 2021)
is not an adverse benefit determination.
(D)
"Appeal" is the
member's request for an MCE to review an adverse benefit
determination.
(C)(E) "Authorized
representative" has the same meaning as in rule
5160:1-1-01 of the
Administrative Code.
(F)
"Care management system" means the system established
by the Ohio department of medicaid (ODM) in accordance with section
5167.03 of the Revised
Code.
(D)(G) "Consumer contact
record (CCR)" means the record containing demographic health-related
information provided by an eligible individual, managed care member, or
the Ohio department of medicaid (ODM)
ODM that is used by the Ohio medicaid consumer hotline
to process membership transactions.
(E)(H) "Coordination of
benefits (COB)" means a procedure establishing the order in which health care
entities pay their claims as described in rule
5160-26-09.1 of the
Administrative Code.
(F)(I) "Covered services"
means those medical services set forth in rule
5160-26-03 of the Administrative
Code or a subset of those medical services.
(G)(J) "Eligible
individual" means any medicaid recipient who is a legal resident of the managed
care service area and is in one of the categories specified in
rule
5160-26-02 of the Administrative
Code.
the MCO's provider agreement with
ODM.
(H)(K) "Emergency medical
condition" means a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such 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 any of the following:
placing the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy; serious
impairment to bodily functions; or serious dysfunction of any bodily organ or
part.
(I)(L) "Emergency
services" means covered inpatient services, outpatient services, or medical
transportation services that are provided by a qualified provider and are
needed to evaluate, treat, or stabilize an emergency medical condition. As used
in this chapter, providers of emergency services also include physicians or
other health care professionals or health care facilities not under employment
or under contractual arrangement with
an
MCO
an MCE.
(J)(M) "Explanation of
benefits (EOB)," otherwise known as "explanation of payment (EOP)," or
"remittance advice (RA)," means the information sent to providers and/ or
members by any other third party payer, or
MCO
MCE, to explain
the adjudication of a claim.
(K)(N) "Federally
qualified health center (FQHC)" has the same meaning as in rule
5160-28-01 of the Administrative
Code.
(L)(O) "Fraud" means any
intentional deception or misrepresentation made by an individual or entity with
the knowledge that the deception could result in some unauthorized benefit to
the individual, the entity, or some other person. This includes any act that
constitutes fraud under applicable federal or state law. Member fraud means the
altering of information or documents in order to fraudulently receive
unauthorized benefits or to knowingly permit others to use the member's
identification card to obtain services or supplies.
(P)
"Grievance" is
the member's expression of dissatisfaction about any matter other than an
adverse benefit determination. Grievances may include, but are not limited to,
the quality of care or services provided, and aspects of interpersonal
relationships such as rudeness of a provider or employee, or failure to respect
the member's rights regardless of whether remedial action is requested.
Grievance includes a member's right to dispute an extension of time proposed by
an MCE to make an authorization decision.
(M)(Q) "Healthchek"
services, otherwise known as early and periodic screening, diagnostic, and
treatment (EPSDT) services, are comprehensive preventive health services
available to individuals under twenty-one years of age who are enrolled in
medicaid as those services are described in rule
5160-1-14 of the Administrative
Code.
(N)(R) "Hospital" means an
institution located at a single site that is engaged primarily in providing to
inpatients, by or under the supervision of an organized medical staff of
physicians licensed under Chapter 4731. of the Revised Code, diagnostic
services and therapeutic services for medical diagnosis and treatment or
rehabilitation of injured, disabled, or sick persons. "Hospital" does not mean
an institution that is operated by the United States government.
(O)(S)
"Hospital services" means those inpatient and outpatient services that are
generally and customarily provided by hospitals.
(P)(T) "Inpatient
facility" means an acute or general hospital.
(Q)(U) "Intermediate care
facility for individuals with intellectual disabilities (ICF/IID)" has the same
meaning as in section
5124.01 of the Revised
Code.
(R)(V) "Managed care"
means a health care delivery system operated by the state in accordance with 42
C.F.R. part
438 (October 1,
2019
2021).
(W)
"Managed care entity (MCE)" means a managed care
organization, the single pharmacy benefit manager, a MyCare Ohio plan as
defined in rule
5160-58-01 of the Administrative
Code, and the OhioRISE plan as defined in rule
5160-59-01 of the Administrative
Code.
(S)(X) "Managed care
organization (MCO)"
or "managed care plan
(MCP)"
has the same definition as in
42
C.F.R 438.2 (October 1, 2021)
means
and is
a health insuring corporation (HIC) licensed in the state of Ohio that enters
into a managed care provider agreement with ODM.
(T)(Y) "Medicaid" means
medical assistance as defined in section
5162.01 of the Revised
Code.
(U)(Z) "Medicaid fraud
control unit (MCFU)" means an identifiable entity of state or federal
government charged with the investigation and prosecution of fraud and related
offenses within medicaid.
(V)(AA) "Medically
necessary," or "medical necessity," has the same meaning as in rule
5160-1-01 of the Administrative
Code.
(W)(BB) "Medicare" means
the federally financed medical assistance program defined in
42 U.S.C.
1395 (as in effect
July 1, 2020
July 1,
2022).
(X)(CC) "Member"
or "enrollee" means a medicaid recipient
who has selected
or been assigned to
MCO membership or has been assigned to an
MCO
an MCE for the purpose of receiving
health care services.
(DD)
"Network provider" means any provider, group of
providers, or entity that has a network provider contract with the MCE in
accordance with rule
5160-26-05 of the Administrative
Code and receives medicaid funding directly or indirectly to order, refer, or
render covered services as a result of the MCE's provider agreement or contract
with ODM.
(EE)
"Non-contracting provider" means any provider with an
ODM provider agreement who does not contract with an MCE, but delivers health
care services to an MCE's members.
(FF)
"Non-contracting provider of emergency services" means any person, institution
or entity that does not contract with an MCE, but provides emergency services
to an MCE's members, regardless of whether that provider has an ODM provider
agreement.
(GG)
"Notice of action (NOA)" is the written notice an MCE
provides to members when an adverse benefit determination has occurred or will
occur.
(Y)(HH) "Nursing facility"
has the same meaning as in section
5165.01 of the Revised
Code.
(Z)(II) "Ohio medicaid
consumer hotline" means the managed care enrollment broker and customer service
agent for individuals receiving Ohio medicaid services.
(AA)(JJ)
"Oral interpretation services" means services provided to a limited-reading
proficient eligible individual or member to ensure that he or she receives
MCO
MCE
information in a format and manner that is easily understood by the eligible
individual or member.
(BB)(KK) "Oral translation
services" means services provided to a limited-English proficient eligible
individual or member to ensure that he or she receives
MCO
MCE
information translated into the primary language of the eligible individual or
member.
(CC)(LL) "Pending
member
"
," or "pending
enrollee," means an eligible individual who has selected or been
assigned to
an MCO
an MCE but whose
MCO membership
in the
MCE is not yet effective.
(DD)(MM)
"Post-stabilization care services" means covered services related to an
emergency medical condition that a treating provider views as medically
necessary after an emergency medical condition has been stabilized in order to
maintain the stabilized condition, or under the circumstances described in
42
C.F.R.
422.113 (October 1,
2019
2021) to
improve or resolve the member's condition.
(EE)(NN) "Premium" means
the monthly payment amount per member to which the MCO is entitled as
compensation for performing its obligations in accordance with Chapter 5160-26
of the Administrative Code and/or the provider agreement with ODM.
(FF)(OO)
"Primary care provider (PCP)" means an individual physician (M.D. or D.O.), a
physician group practice, an advanced practice registered nurse as defined in
section
4723.01 of the Revised Code, an
advanced practice nurse group practice within an acceptable specialty, or a
physician assistant who meets the requirements of rule
5160-4-03 of the Administrative
Code contracting with an MCO to provide services as specified in rule
5160-26-03.1 of the
Administrative Code. Acceptable PCP specialty types include family/general
practice, internal medicine, pediatrics, and obstetrics/gynecology
(OB/GYNs).
(GG)(PP) "Protected health
information (PHI)" means information received from or on behalf of ODM that
meets the definition of PHI as defined by
45
C.F.R.
160.103 (October 1,
2019
2021).
(HH)(QQ) "Provider" means
a hospital, health care facility, physician, dentist, pharmacy, or otherwise
licensed or certified appropriate individual or entity that is authorized to or
may be entitled to reimbursement for health care-related services rendered to
an MCO's
an
MCE's member.
(II)(RR) "Provider
agreement" means a formal agreement between ODM and an MCO for the provision of
medically necessary services to medicaid recipients who are enrolled in the
MCO.
(JJ)(SS) "Provider
panel
network"
," otherwise known
as "panel" or "network," means
the
MCO's
an MCE's contracted providers
available to the
MCO's
MCE's
general
membership
members.
(KK)(TT)
"Qualified family planning provider (QFPP)" means any public or nonprofit
health care provider that complies with guidelines/standards set forth in
42 U.S.C.
300 (as in effect
July 1, 2020
July 1,
2022), and receives either Title X funding or family planning funding
from the Ohio department of health.
(UU)
"Respite
services" are services that provide short-term, temporary relief to the
informal unpaid caregiver of a managed care member in order to support and
preserve the primary care giving relationship.
(LL)(VV) "Risk" or
"underwriting risk" means the possibility that an MCO may incur a loss because
the cost of providing services may exceed the payments made by ODM to the
contractor for services covered under the provider agreement.
(MM)(WW)
"Rural health clinic (RHC)" has the same meaning as in rule
5160-28-01 of the Administrative
Code.
(NN)(XX) "Self-referral"
means the process by which an MCO member may access certain services without
prior approval from the PCP or the MCO.
(OO)(YY) "Service area"
means the geographic area specified in the MCO's provider agreement where the
MCO agrees to provide Medicaid services to members residing in those
areas.
(ZZ)
"Single case agreement" means a contract with an
out-of-network provider to provide services to an MCE's member on a one-time,
individual, or limited basis.
(AAA)
"Single
pharmacy benefit manager (SPBM)" is a prepaid ambulatory health plan as defined
in 42 C.F.R. 438.2
(October 1, 2021) and the state pharmacy benefit manager selected under section
5167.24 of the Revised code which is responsible for processing all pharmacy
claims under the care management system. The SPBM service area is
statewide.
(BBB)
"SPBM contract" means a formal agreement between ODM
and the SPBM for the provision of medically necessary pharmacy services to
medicaid recipients who are enrolled in the SPBM.
(PP)(CCC)
"State cut-off" means the eighth state working day prior to the end of a
calendar month.
(DDD)
"State hearing" means the process set forth in 42 C.F.R
431, Subpart E (October 1, 2021) and division 5101:6 of the Administrative
Code.
(QQ)(EEE) "Subcontract"
means a written contract between
an MCO
an MCE and a third party, including the
MCO's
MCE's
parent company or any subsidiary corporation owned by the
MCO's
MCE's
parent company, or between the third party and a fourth party, or between any
subsequent parties, to perform a specific part of the obligations specified
under the MCO's provider agreement
or the SPBM's
contract with ODM.
(RR)(FFF) "Subcontractor"
means
an individual or entity
any party that has entered into a
subcontract
with an MCE to perform a specific
part of the obligations specified under the MCO's provider agreement
or the SPBM's contract with ODM.
A provider or network provider is not a subcontractor
by virtue of the provider's contract with an MCE.
(SS)(GGG)
"Third party" means the same as in section
5160.35 of the Revised
Code.
(TT)(HHH) "Third party
administrator" means any entity used in accordance with the provisions of this
chapter to manage or administer a portion of services in fulfillment of the
provider agreement with ODM.
(UU)(III) "Third party
benefit" means any health care service(s) available to members through any
medical insurance policy or through some other resource that covers medical
benefits and the payment for those services is either completely the obligation
of the third party payer (TPP) or in part the obligation of the member, the
TPP, and/ or the
MCO
MCE.
(VV)(JJJ) "Third party
claim" or "COB claim" means any claim submitted to
the MCO
an MCE for
reimbursement after all TPPs have met their payment obligations. In addition,
the following will be considered third party claims by
the MCO
an
MCE:
(1) Any claim received by the
MCO
MCE that
shows no prior payment by a TPP, but the
MCO's
MCE's records
indicate that the member has third party benefits.
(2) Any claim received by the
MCO
MCE that
shows no prior payment by a TPP, but the provider's records indicate that the
member has third party benefits.
(WW)(KKK) "Third party
liability (TPL)" means the payment obligations of the TPP for health care
services rendered to a member when the member also has third party benefits as
described in paragraph (
UU
EEE) of this rule.
(XX)(LLL) "Third party
payer (TPP)" means an individual, an entity, or a program responsible for
adjudicating and paying claims for third party benefits rendered to an eligible
member.
(YY)(MMM) "Title X
services" means services and supplies allowed under
42 U.S.C.
300 (as in effect
July 1, 2020
July 1,
2022), and provided by a qualified family planning provider.
(ZZ)(NNN)
"Tort action," or "subrogation," means the right of ODM to recover payment
received from a third party payer who may be liable for the cost of medical
services and care arising out of an injury, disease, or disability to the
member.
(AAA)(OOO) "Waste" means
payment for or the attempt to obtain payment for items or services when there
may be no intent to deceive or misrepresent, but poor or inefficient billing or
treatment methods result in unnecessary costs.
