2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix B. DefinitionsTerm Definition Sourceelectronic health record(EHR)HSDemergency medicalconditionemergency servicesencounterencounter datafair hearingfederally qualified healthcenter (FQHC)fiscal management agency(FMA)fraudfrontiergrievancehome and communitybasedservices (HCBS)health educationMeans a record in digital format that is a systematic collection of electronic health information.Electronic health records may contain a range of data, including demographics, medicalhistory, medication and allergies, immunization status, laboratory test results, radiologyimages, vital signs, personal statistics such as age and weight, and billing information.Means a medical or behavioral health condition manifesting itself through acute symptoms ofsufficient severity (including severe pain) such that a prudent layperson with averageknowledge of health and medicine could reasonably expect the absence of immediatemedical attention to result in: (i) placing the members’ health (or, with respect to a pregnantwoman, the health of the woman or her unborn child) in serious jeopardy; (ii) seriousimpairment to bodily functions; (iii) serious dysfunction of any bodily organ or part; or (iv)serious disfigurement to the member.Means covered services that are inpatient or outpatient and are (i) furnished by a provider thatis qualified to furnish these services and (ii) needed to evaluate or stabilize an emergencymedical condition.Means a record of any claim adjudicated by the MCO or any of its subcontractors for amember, including Medicare claims for which there is no Medicaid reimbursement amountand/or a record of any service or administrative activity provided by the MCO or any of itssubcontractors for a member that represents a member-specific service or administrativeactivity, regardless of whether that service was adjudicated as a claim or whether payment forthe service was made.Information about claims adjudicated by the MCO for services rendered to its members. Suchinformation includes whether claims were paid or denied and any capitated and subcapitatedarrangements.Means the administrative decision-making process that requires aggrieved individuals begiven the opportunity to confront the evidence against them and have their evidenceconsidered by an impartial finder of fact in a meaningful time and manner.Means an entity that meets the requirements of, and receives a grant and funding pursuant to,the Public Health Service Act. An FQHC also includes an outpatient health program, a facilityoperated by a tribe or tribal organization under the Indian Self-Determination Act (PL 93-638),and an urban Indian organization receiving funds under Title V of the Indian Health CareImprovement Act, codified at 25 USC 1601 et seq.Means an entity contracting with the state that provides the fiscal administration functions formembers receiving the self-directed community benefit. The FMA must be an entity operatingunder Section 3504 of the IRS code, Revenue Procedure 70-6 and Notice 2003-70, as theagent to members for the purpose of filing certain federal tax forms and paying federal incometax withholding, FICA and FUTA taxes. The FMA also files state income tax withholding andunemployment insurance tax forms, pays the associated taxes, and processes payroll basedon the eligible self-directed community benefit services authorized and provided.Means an intentional deception or misrepresentation by a person or an entity, with theknowledge that the deception could result in some unauthorized benefit to himself or someother person. It includes any act that constitutes fraud under applicable federal or state law.Means the following counties in New Mexico: Catron, Harding, DeBaca, Union, Guadalupe,Hidalgo, Socorro, Mora, Sierra, Lincoln, Torrance, Colfax, Quay, San Miguel, and Cibola.Means an expression of dissatisfaction about any matter or aspect of the MCO or itsoperation.Home and community-based services (HCBS) provide opportunities for Medicaidbeneficiaries to receive services in their own home or community. These programs serve avariety of targeted populations groups, such as people with mental illnesses, intellectualdisabilities, and/or physical disabilities.Means programs, services, or promotions that are designed or intended to inform the MCO’sactual or potential members about issues related to healthy lifestyles, situations that affect orinfluence health status, or methods or modes of medical treatment.HSDHSDHSDHSDHSDHSDHSDHSDHSDHSDCMSHSDB-42014 Practitioner and Provider Manual - Ver. 3