W. Va. Code R. § 114-56-2

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-56-2 - Definitions

2.1. "Accountability" means the responsibility of a department or individual for achieving defined goals.

2.2. "Appropriateness" means the extent to which a particular procedure, treatment, test or service is clearly indicated, not excessive, adequate in quantity and provided in the setting best suited to the patient's or member's needs.

2.3. "Clinician" means a state-recognized provider including, but not limited to, physicians, psychologists and psychiatrists who specialize in clinical studies or practice.

2.4. "Commissioner" means the West Virginia Insurance Commissioner.

2.5. "Coordinating provider" means the provider of a particular limited health service who is chosen or designated for each subscriber and who will be responsible for coordinating the provision of that particular limited health service to the subscriber, including necessary referrals to other providers of the limited health service: Provided, That if a subscriber is also enrolled in a health maintenance organization, the coordinating provider shall send a written report at least annually to the subscriber's primary care physician, as defined in article twenty-five-a of this chapter, describing the limited health service provided to the subscriber: Provided, however, That the coordinating provider may disclose data or information only as permitted under W. Va. Code '33-25D-12.

2.6. "Credentialing" means the process by which a prepaid limited health service organization authorizes, contracts with or employs providers, who are licensed to practice independently, to provide services to its members.

2.7. "DEA" means Drug Enforcement Administration, the federal agency that issues licenses to prescribe and dispense scheduled drugs.

2.8. "Delegation" or "delegated" means the formal process by which a prepaid limited health service organization gives a contractor the authority to perform certain functions on its behalf, such as credentialing, utilization review and quality assurance. A prepaid limited health service organization can delegate the authority to perform a function but cannot delegate the responsibility for assuring the function is performed properly.

2.9. "Governing body" means an individual, group or agency with the ultimate authority and responsibility for the overall operation of the organization.

2.10. "Limited health service" and "health care service" means mental or behavioral health services (including mental illness, mental retardation, developmental disabilities, substance abuse, and chemical dependency), together with any services or goods included in the furnishing to any individual of a limited health service. "Limited health services" does not include inpatient services, hospital surgical services or emergency services except as such services are provided incident to and directly related to a limited health service set forth in this subsection.

2.11. "Member," "subscriber" or "enrollee" means an individual who has been voluntarily enrolled in a prepaid limited health service organization, including individuals on whose behalf a contractual arrangement has been entered into with a prepaid limited health service organization to receive limited health services.

2.12. "Oversight" means the monitoring and direction of a set of activities by individuals responsible for the execution of the activities resulting in the achievement of desired outcomes.

2.13. "Practice guidelines" or "protocols" means systematically developed statements to assist patient and provider decisions about appropriate health care for specific clinical circumstances. Practice guidelines are usually based on such authoritative sources as clinical literature and expert consensus.

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

2.15. "Prepaid limited health service organization" means a public or private organization which provides, or otherwise makes available to enrollees, limited health services and which:

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

b. Provides limited health services primarily:

1. Directly through an exclusive panel of physicians or other providers who are employees or partners of the organization;

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

3. Some combination of paragraphs 1 and 2 of this subdivision.

2.16. "Provider" means any physician or other person or organization licensed or otherwise authorized in this state to furnish a health care service.

2.17. "Quality assurance" means an ongoing program designed to objectively and systematically monitor and evaluate the quality and appropriateness of the enrollee's care, pursue opportunities to improve the enrollee's care and to resolve identified problems at the prevailing professional standard of care.

2.18. "Quality improvement work plan" means an annual plan that describes with timeliness the specific planned quality assurance activities that will be carried out within the quality assurance program.

2.19. "Quality of care" means the degree to which limited health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

2.20. "Treatment record" means the record in which clinical information relating to the provision of physical, social and mental services is recorded and stored either electronically or on paper.

2.21. "Utilization management" 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. § 114-56-2