2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix B. DefinitionsTerm Definition Sourcenear missDefined as “an occurrence with potentially important safety-related effects, which, in the endwas prevented from developing into actual consequences.”non-contract provider Means an individual provider, clinic, group, association, or facility that provides coveredservices and that does not have a contract with the MCO.HSDnon-Medicaid Contractornot otherwise Medicaideligiblenursing facility (NF)otherwise Medicaid eligibleoutreachPatient Protection andAffordable Care Act(PPACA)patient-centered medicalhome (PCMH)post-stabilization servicespharmacy networkPresbyterian improvementmodelprimary care provider(PCP)Means the entity contracting with the Collaborative to provide behavioral health services withthe use of non-Medicaid funds.Refers to individuals not eligible for Medicaid services under New Mexico’s Medicaid StatePlan.Means a licensed Medicare/Medicaid facility certified in accordance with 42 CFR § 483 toprovide inpatient room, board, and nursing services to members who require these serviceson a continuous basis but who do not require hospital care or direct daily care from aphysician.Refers to individuals who are eligible for Medicaid services under New Mexico’s MedicaidState Plan.Means, among other things, educating or informing the MCO’s members about CentennialCare, managed care, and health issues.Means Public Law 111-148 (2010) and the Health Care and Education Reconciliation Act of2010 (Public Law 111-152 (2010).Means a team-based model of care led by a personal physician who provides continuous andcoordinated care throughout a patient's lifetime to maximize health outcomes.Means covered services relating to an emergency medical condition that are provided after amember is stabilized in order to maintain the stabilized condition or, under the circumstancesdescribed in 42 CFR § 438.114(e), to improve or resolve the member’s condition.Includes licensed retail pharmacies, long-term care pharmacies, home infusion, I/T/Uprovider, school-based centers, mail order pharmacy, and specialty pharmacies. The ratio ofproviders in this network to members is determined by state and federal regulations.Provides the foundation for process-driven execution and excellence across our organization.This model guides our ongoing improvement of operational processes and provides acommon quality framework for measuring, monitoring, and communicating the of results ofimprovement initiatives.Means an individual who is a contract provider and has the responsibility for supervising,coordinating, and providing primary health care to members, initiating referrals for specialistcare and maintaining the continuity of the member’s care. Can include family practitioners,general practitioners, general internists, pediatricians, certified physician assistants, andcertified nurse practitioners, as well as other specialists that elect to perform in the role ofprimary care.Project ECHOMeans the Extension for Community Healthcare Outcomes program, conducted by theHSDUniversity of New Mexico School of Medicine. The program works to develop the capacity tosafely and effectively treat chronic, common, and complex diseases in rural and underservedareas and to monitor the outcomes of this treatment.promotorasAlso known as community health workers (CHWs), lay health workers, and advocates for PMmembers who assist individuals and families in obtaining the knowledge and skills necessaryto achieve optimal health and well-being.providerMeans an institution, facility, agency, physician, health care practitioner, or other entity that is HSDlicensed or otherwise authorized to provide any of the covered services in the state in whichthey are furnished. Providers include individuals and vendors providing services to membersthrough the Self-Directed Community Benefit.provider satisfactionAnnual provider satisfaction survey that covers contract providers and follows NCQAsurveyguidelines to the extent applicable.HSDprovider workgroup Means the workgroup consisting of representatives from all of the MCOs, HSD, the HSDHSDHSDHSDHSDHSDHSDHSDHSDPMHSDB-72014 Practitioner and Provider Manual - Ver. 3