WAC 388-538-0050 Definitions.

The following definitions and abbreviations and those found in chapter 388-500-0005 WAC, Medical definitions, apply to this chapter. 

"Action" means:

1. The denial or limited authorization of a requested service, including the type or level of service;

2. The reduction, suspension, or termination of a previously authorized service;

3. The denial, in whole or in part, of payment for a service;

4. The failure to provide services in a timely manner, as defined by the state; or

5. The failure of an MCO to act within the time frames provided in 42 C.F.R. 438.408(b).

"Ancillary health services" means health services ordered by a provider, including but not limited to, laboratory services, radiology services, and physical therapy.

"Appeal" means a formal request by a provider or covered enrollee for reconsideration of a decision such as a utilization review recommendation, a benefit payment, an administrative action, or a quality of care or service issue, with the goal of finding a mutually acceptable solution.

"Assign" or "assignment" means that MAA selects a managed care organization (MCO) or primary care case management (PCCM) provider to serve a client who lives in a mandatory enrollment area and who has failed to select an MCO or PCCM provider.

"Auto enrollment" means that MAA automatically enrolls a client into an MCO in his or her area, rather than waiting for the client to enroll with an MCO.

"Basic health (BH)" means the health care program authorized by title 70.47 RCW and administered by the health care authority (HCA). MAA considers basic health to be third-party coverage, however, this does not include basic health plus (BH.+).

"Children's health insurance program (CHIP)" means the health insurance program authorized by Title XXI of the Social Security Act and administered by the department of social and health services (DSHS). This program also is referred to as the state children's health insurance program (SCHIP).

"Children with special health care needs" means children identified by the department of social and health services (DSHS) as having special health care needs. This includes:

1. Children designated as having special health care needs by the department of health (DOH) and served under the Title V program;

2. Children who meet disability criteria of Title 16 of the Social Security Act (SSA); and

3. Children who are in foster care or who are served under subsidized adoption.

"Client" means an individual eligible for any medical program who is not enrolled with a managed care organization (MCO) or primary care case management (PCCM) provider. In this chapter, client refers to a person before the person is enrolled in managed care, while enrollee refers to an individual eligible for any medical program who is enrolled in managed care.

"Complaint" means an oral or written expression of dissatisfaction by an enrollee.

"Emergency medical condition" means a condition meeting the definition in 42 U.S.C. 1396u-2 (b)(2)(C).

"Emergency services" means services as defined in 42 U.S.C. 1396u-2 (b)(2)(B).

"End enrollment" means an enrollee is currently enrolled in managed care, either with a managed care organization (MCO) or with a primary care case management (PCCM) provider, and requests to discontinue enrollment and return to the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-0130. This is also referred to as "disenrollment."

"Enrollee" means an individual eligible for any medical program who is enrolled in managed care through a managed care organization (MCO) or primary care case management (PCCM) provider that has a contract with the state.

"Enrollees with chronic conditions" means persons having chronic and disabling conditions, including persons with special health care needs that meet all of the following conditions:

1. Have a biologic, psychologic, or cognitive basis;

2. Have lasted or are virtually certain to last for at least one year; and

3. Produce one or more of the following conditions stemming from a disease:

   1. Significant limitation in areas of physical, cognitive, or emotional function;

   2. Dependency on medical or assistive devices to minimize limitation of function or activities; or

   3. In addition, for children, any of the following:

      1. Significant limitation in social growth or developmental function;

      2. Need for psychologic, educational, medical, or related services over and above the usual for the child's age; or

      3. Special ongoing treatments, such as medications, special diet, interventions, or accommodations at home or school.

"Exemption" means a client, not currently enrolled in managed care, makes a pre-enrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 388-538-0080.

"Health care service" or "service" means a service or item provided for the prevention, cure, or treatment of an illness, injury, disease, or condition.

"Healthy options contract or HO contract" means the agreement between the department of social and health services (DSHS) and a managed care organization (MCO) to provide prepaid contracted services to enrollees.

"Healthy options program or HO program" means the medical assistance administration's (MAA) prepaid managed care health program for Medicaid-eligible clients and CHIP clients.

"Managed care" means a comprehensive system of medical and health care delivery including preventive, primary, specialty, and ancillary health services. These services are provided either through a managed care organization (MCO) or primary care case management (PCCM) provider.

"Managed care organization" or "MCO" means a health maintenance organization or health care service contractor that contracts with the department of social and health services (DSHS) under a comprehensive risk contract to provide prepaid health care services to eligible medical assistance administration (MAA) clients under MAA's managed care programs.

"Nonparticipating provider" means a person or entity that does not have a written agreement with a managed care organization (MCO) but that provides MCO-contracted health care services to managed care enrollees with the authorization of the MCO. The MCO is solely responsible for payment for MCO-contracted health care services that are authorized by the MCO and provided by nonparticipating providers.

"Participating provider" means a person or entity with a written agreement with a managed care organization (MCO) to provide health care services to managed care enrollees. A participating provider must look solely to the MCO for payment for such services.

"Primary care case management (PCCM)" means the health care management activities of a provider that contracts with the department to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services.

"Primary care provider (PCP)" means a person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides health services to a client or an enrollee, initiates referrals for specialist and ancillary care, and maintains the client's or enrollee's continuity of care.

"Prior authorization (PA)" means a process by which enrollees or providers must request and receive MAA approval for certain medical services, equipment, drugs, and supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization. See WAC 388-501-0165.

"Timely" - in relation to the provision of services, means an enrollee has the right to receive medically necessary health care without unreasonable delay.