WAC 182-538-0050

Effective July 1, 2011

WAC 182-538-0050 Definitions

The following definitions and abbreviations and those found in Chapter 182-500 WAC, Medical definitions, apply to this chapter. References to managed care in this chapter do not apply to mental health managed care administered under chapter 388-865 WAC.

     "Action" means one or more of the following:

     (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 a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. 438.408(b).

     "Agency" - See WAC 182-500-0010.

     "Ancillary health services" means healthcare services that are auxiliary, accessory, or secondary to a primary healthcare service.

     "Appeal" means a request by an enrollee or provider with written permission of an enrollee for reconsideration of an action.

     "Assign" or "assignment" means the agency selects an MCO or primary care case management (PCCM) provider to serve a client who has not selected an MCO or PCCM provider.

     "Auto enrollment" means the agency has automatically enrolled a client into an MCO in the client's area of residence.

     "Basic health" or "BH" means the healthcare program authorized by chapter 70.47 RCW and administered by the agency.

     "Basic health plus" -- Refer to chapter 182-24 WAC .

     "Client" means, for the purposes of this chapter, an individual eligible for any medical assistance program, including managed care programs, but who is not enrolled with an MCO or PCCM provider. In this chapter, "client" refers to a person before he or she is enrolled in managed care, while "enrollee" refers to an individual eligible for any medical assistance program who is enrolled in managed care.

     "Disenrollment" - See "end enrollment."

     "Emergency medical condition" means a condition meeting the definition in 42 C.F.R. 438.114(a).

     "Emergency services" means services defined in 42 C.F.R. 438.114(a).

     "End enrollment" means ending the enrollment of an enrollee for one of the reasons outlined in WAC 182-538-130.

     "Enrollee" means an individual eligible for any medical assistance program enrolled in managed care with an MCO or PCCM provider that has a contract with the state.

     "Enrollee's representative" means an individual with a legal right or written authorization from the enrollee to act on behalf of the enrollee in making decisions.

     "Enrollees with special health care needs" means enrollees having chronic and disabling conditions and the 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:

     (a) Significant limitation in areas of physical, cognitive, or emotional function;

     (b) Dependency on medical or assistive devices to minimize limitation of function or activities; or

     (c) In addition, for children, any of the following:

     (i) Significant limitation in social growth or developmental function;

     (ii) Need for psychological, educational, medical, or related services over and above the usual for the child's age; or

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

     "Exemption" means agency approval of a client's preenrollment request to remain in the fee-for-service delivery system for one of the reasons outlined in WAC 182-538-130.

     "Grievance" means an expression of dissatisfaction about any matter other than an action, as "action" is defined in this section.

     "Grievance system" means the overall system that includes grievances and appeals handled at the MCO level and access to the agency's hearing process.

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

     "Healthy Options program" or "HO program" means the agency's prepaid managed care health program for medicaid-eligible clients and clients enrolled in the state children's health insurance program (SCHIP).

     "Managed care" means a comprehensive healthcare delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided through either an MCO or PCCM provider.

     "Managed care contract" means the agreement between the agency and an MCO to provide prepaid contracted services to enrollees.

     "Managed care organization" or "MCO" means an organization having a certificate of authority or certificate of registration from the office of insurance commissioner that contracts with the agency under a comprehensive risk contract to provide prepaid healthcare services to eligible clients under the agency's managed care programs.

     "Mandatory enrollment" means the agency's requirement that a client enroll in managed care.

     "Mandatory service area" means a service area in which eligible clients are required to enroll in an MCO.

     "Nonparticipating provider" means a healthcare provider that does not have a written agreement with an MCO but that provides MCO-contracted healthcare services to managed care enrollees with the MCO's authorization.

     "Participating provider" means a healthcare provider with a written agreement with an MCO to provide healthcare services to the MCO's managed care enrollees. A participating provider must look solely to the MCO for payment for such services.

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

     "Primary care provider" or "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" or "PA" means a process by which enrollees or providers must request and receive agency approval for services provided through the agency's fee-for-service system, or MCO approval for services provided through the MCO, 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.

     "Timely" means in relation to the provision of services, an enrollee has the right to receive medically necessary healthcare as expeditiously as the enrollee's health condition requires. In relation to authorization of services and grievances and appeals, "timely" means according to the agency's managed care program contracts and the time frames stated in this chapter.

     "Washington medicaid integration partnership" or "WMIP" means the managed care program that is designed to integrate medical, mental health, chemical dependency treatment, and long-term care services into a single coordinated health plan for eligible aged, blind, or disabled clients.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.