All terms contained in these rules shall have the same
meaning as defined in the Health Maintenance Organization Act of 1986, as
amended. See T.C.A. § 56-32-202. As used in these rules, unless the
context dictates otherwise, the definitions are as follows:
(1) Basic health care services. All those
health services which a defined population might reasonably require in order to
be in good health, including as a minimum, but not limited to, emergency care,
inpatient hospital and physician care, ambulatory physician care and outpatient
preventive medical services.
Centers for Medicare & Medicaid Services (CMS) is a federal agency within
the U.S. Department of Health and Human Services. CMS runs the Medicare and
Medicaid programs which are national health care programs that benefit about
seventy-five (75) million Americans. With the Health Resources and Services
Administration, CMS runs the State Children's Health Insurance Program (SCHIP),
a program that is expected to cover many of the approximately ten (10) million
uninsured children in the United States.
(3) Certificate of Authority (COA or
license). The license issued by the Tennessee Department of Commerce and
Insurance that permits a person or organization to establish and operate a
health maintenance organization.
(4) Clean claim. A claim received by an HMO
for adjudication, and which requires no further information, adjustment or
alteration by the provider of the services in order to be processed and paid by
the health insurer. A claim is clean if it has no defect or impropriety
(including any lack of any required substantiating documentation) or particular
circumstance requiring special treatment that prevents timely payment from
being made on the claim under this section.
(5) Department. The Tennessee Department of
(6) Department of
Commerce and Insurance. The Tennessee Department of Commerce and Insurance
(7) Department of Health.
The Tennessee Department of Health (TDH).
(8) Emergency Care. Health services and care
provided for a medical condition (illness, disease, accident, or injury)
manifesting itself by acute symptoms of sufficient severity (including severe
pain), that a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate medical
attention to potentially result in (a) placing the person's health in serious
jeopardy, (b) serious impairment to bodily functions, or (c) dysfunction of a
bodily organ or part.
An individual who is enrolled in a health maintenance organization.
(10) Governing Body. The board of directors
or other person or entity that governs the operation of the health maintenance
organization in the State of Tennessee.
(11) Grievance. A written complaint as
defined in T.C.A. § 56-32-210(a)(2)(A). A grievance usually expresses
dissatisfaction with a decision or action of the health maintenance
organization or its providers (e.g., coverage decisions, pre-authorization
requests, quality of care, accessibility of care) and seeks
(12) Health care
services. Any services included in the furnishing to any individual of medical
or dental care, or hospitalization, or incidental to the furnishing of such
care or hospitalization, as well as the furnishing to any person of any and all
other services for the purpose of preventing, alleviating, curing, or healing
human illness, injury or physical disability.
(13) Health Maintenance Organization (HMO).
Any person or organization that undertakes to provide or arrange for basic
health care services to enrollees on a prepaid basis. The person or
organization may provide physician services directly through physician
employees or under arrangements with individual physicians or a group or groups
of physicians. The person or organization may also provide or arrange for other
health care services on a prepayment or other financial basis. An HMO may also
provide or arrange for additional health care services.
(14) Member. An individual who is enrolled in
a health maintenance organization (i.e., an enrollee).
(15) National Committee for Quality Assurance
(NCQA). An independent 501(c)(3) non-profit organization whose mission is to
improve health care quality.