W. Va. Code R. § 114-51-2

Current through Register Vol. XLI, No. 49, December 6, 2024

Section 114-51-2 - Definitions

2.1. "Concurrent review" means the process of continued reassessment of the medical necessity and appropriateness of inpatient care during hospitalization.

2.2. "Criteria" means systematically developed statements used to assess the appropriateness of specific health care decisions, services and outcomes.

2.3. "Health maintenance organization" or "HMO" means a public or private organization which provides, or otherwise makes available to enrollees, health care services, including at a minimum basic health care services, which:

a. Receives premiums for the provision of basic health care services to enrollees on a prepaid per capita or prepaid aggregate fixed sum basis, excluding copayments;

b. Primarily provides physicians' services:

1. Directly through physicians who are either employees or partners of the organization;

2. Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice arrangement; or

3. Through some combination of paragraphs 1 and 2 of this subdivision;

c. Assures the availability, accessibility and quality, including appropriate utilization, of the health care services that it provides or makes available through clearly identifiable focal points of legal and administrative responsibility; and

d. Offers services through an organized delivery system, in which a primary care physician is designated for each subscriber upon enrollment. The primary care physician is responsible for coordinating the health care of the subscriber and is responsible for referring the subscriber to other providers when necessary: Provided, that when dental care is provided by the health maintenance organization the dentist selected by the subscriber from the list provided by the health maintenance organization shall coordinate the covered dental care of the subscriber, as approved by the primary care physician or the health maintenance organization.

2.4. "Member," "subscriber" or "enrollee" means an individual who has been enrolled in a health maintenance organization, including individuals on whose behalf a contractual arrangement has been entered into with a health maintenance organization to receive health care services.

2.5. "Preauthorization" means prior assessment that proposed medical services are covered by the member's benefit plan and are appropriate for a particular member.

2.6. "Qualified medical professional" means a person licensed or certified pursuant to the laws of the state in which he or she practices to provide health care services to persons.

2.7. "Utilization management" or "UM" means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedures and facilities.

W. Va. Code R. § 114-51-2