The following words and terms, when used in this chapter,
have the following meanings, unless the context clearly indicates otherwise:
Act-Article XXI of The Insurance Company
Law of 1921 (40 P. S. §§
991.2101-991.2193).
Ancillary service plan-As defined in
section 2102 of the act (40 P. S. §
991.2102).
Clean claim-As defined in section 2102 of
the act.
Commissioner-The Insurance Commissioner of
the Commonwealth.
Complaint-As defined in section 2102 of
the act.
Department-The Insurance Department of the
Commonwealth.
Emergency service-As defined in section
2102 of the act.
Enrollee-A policyholder, subscriber,
covered person or other individual who is entitled to receive health care
services under a managed care plan. For purposes of the complaint and grievance
processes, the term includes parents of minor enrollees as well as designees or
legal representatives who are entitled or authorized to act on behalf of an
enrollee.
Gatekeeper-A primary care provider
selected by an enrollee or appointed by a managed care plan, or the plan or an
agent of the plan serving as the primary care provider, from whom an enrollee
shall obtain covered health care services, a referral, or approval for covered,
nonemergency health services as a precondition to receiving the highest level
of coverage available under the managed care plan.
Grievance-As defined in section 2102 of
the act.
Health care provider-As defined in
section 2102 of the act.
Health care service-As defined in section
2102 of the act.
IDS-Integrated Delivery System-
(i) A partnership, association, corporation
or other legal entity which does the following:
(A) Enters into a contractual arrangement
with a managed care plan.
(B)
Employs or has contracts with providers (participating providers).
(C) Agrees under its arrangements with a
managed care
plan to do the following:
(I)
Provide or arrange for the provision of a defined set of health care services
to managed care plan members covered under a managed care plan benefits
contract principally through its participating providers.
(II) Assume under the arrangements some
responsibility for conduct, in conjunction with the managed care plan and under
compliance monitoring of the managed care plan's quality assurance, utilization
review, credentialing, provider relations or related functions.
(ii) The IDS may also
perform claims processing and other functions.
Licensed insurer-An individual,
corporation, association, partnership, reciprocal exchange, interinsurer,
Lloyds insurer and other legal entity engaged in the business of insurance, and
fraternal benefit societies as defined in the Fraternal Benefits Societies Code
(40
P. S. §§
1142-101-1142-701), and
preferred provider organizations as defined in section 630 of The Insurance
Company Law of 1921 (40 P. S. §
764a) and
§
152.2 (relating to
definitions).
Managed care plan-
(i) A health care
plan that: uses a
gatekeeper to manage the utilization of health care services; integrates the
financing and delivery of health care services to enrollees by arrangements
with health care providers selected to participate on the basis of specific
standards; and provides financial incentives for enrollees to use the
participating health care providers in accordance with procedures established
by the plan. A managed care plan includes health care arranged through an
entity operating under any of the following:
(A) Section 630 of The Insurance Company Law
of 1921.
(B) The Health Maintenance
Organization Act (40 P. S. §§
1551-1568).
(C) The Fraternal Benefit Societies
Code.
(D) 40 Pa.C.S. Chapter 61
(relating to hospital plan corporations).
(E) 40 Pa.C.S. Chapter 63 (relating to
professional health services plan corporations).
(ii) The term includes an entity, including a
municipality, whether licensed or unlicensed, that contracts with or functions
as a managed care plan to provide health care services to enrollees.
(iii) The term includes managed care plans
that require the enrollee to obtain a referral from any primary care provider
in its network as a condition to receiving the highest level of benefits for
specialty care.
(iv) The term does
not include ancillary service plans as defined by the act or an indemnity
arrangement which is primarily fee for service.
Ongoing course of treatment-A continuous
health care treatment provided to an enrollee by a health care provider which
was initiated prior to and that will continue after the plan's termination of a
contract with a participating provider for reasons other than cause or the
enrollee's coverage by a managed care plan as a new enrollee.
Plan-As defined in section 2102 of the
act.
Primary care provider-As defined in
section 2102 of the act.
Prospective enrollee-For group contracts
or policies, those persons eligible, but not yet enrolled, for coverage as
either a subscriber or dependent of a subscriber. For individual contracts or
policies, a person who meets the eligibility requirements of the managed care
plan.
Provider network-As defined in section
2102 of the act.
Referral-As defined in section 2102 of the
act.
Utilization review-As defined in section
2102 of the act.
Utilization review entity-As defined in
section 2102 of the act.
