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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 120. Waivered Services

12VAC30-120-360. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise. All other words and terms used in this part shall comply with the definitions in the contract and those identified 42 CFR 438.2:

"Adverse benefit determination" means, consistent with 42 CFR 438.400, (i) the denial or limited authorization of a requested service; (ii) the failure to take action or timely take action on a request for service; (iii) the reduction, suspension, or termination of a previously authorized service; (iv) the denial in whole or in part of a payment for a covered service; (v) the failure to provide services within the timeframes required by the state, or for a resident of a rural exception area with only one MCO, the denial of a member's request to exercise his right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; (vi) the denial of a member's request to dispute a financial liability; or (vii) the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Appeal" when applicable to a member means a request to DMAS to review an MCO's internal appeal decision to uphold the contractor's adverse benefit determination. For members, an appeal may only be requested after exhaustion of the MCO's one step internal appeal process. Member appeals to DMAS will be conducted in accordance with regulations at 42 CFR 431 Subpart E and 12VAC30-110-10 through 12VAC30-110-370.

"Appeal" when applicable to an appeal by a provider means a request to DMAS to review an MCO's reconsideration decision. For providers, an appeal may only be requested after exhaustion of the MCO's reconsideration process. Provider appeals to DMAS will be conducted in accordance with the requirements set forth in § 2.2-4000 et seq. of the Code of Virginia and 12VAC30-20-500 et seq.

"Covered services" means Medicaid services as defined in the State Plan for Medical Assistance.

"Day" means calendar day unless otherwise stated.

"Disenrollment" means the process of changing enrollment from one managed care organization (MCO) plan to another MCO, if applicable.

"DMAS" means the Department of Medical Assistance Services.

"Eligible person" means any person eligible for Virginia Medicaid in accordance with the State Plan for Medical Assistance under Title XIX of the Social Security Act.

"Emergency services" means those health care services that are rendered by participating or nonparticipating providers after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in (i) placing the client's health in serious jeopardy; (ii) with respect to a pregnant woman, placing the health of the woman or her unborn child in serious jeopardy; (iii) serious impairment to bodily functions; or (iv) serious dysfunction of any bodily organ or part.

"Exclude" means the removal of a member from the Medallion mandatory managed care program on a temporary or permanent basis.

"External quality review organization" or "EQRO" means an organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality reviews, other external quality review related activities as set forth in 42 CFR 438.358, or both.

"Grievance" means, in accordance with 42 CFR 438.400, an expression of dissatisfaction about any matter other than an "adverse benefit determination." Possible subjects for grievances include the quality of care or services provided; aspects of interpersonal relationships, such as rudeness of a provider or employee; or failure to respect the member's rights.

"Health care professional" means a provider as defined in 42 CFR 438.2.

"Individual" means a person who is eligible for Medicaid who is not yet undergoing enrollment for mandatory managed care and who is not enrolled in a mandatory managed care organization.

"Internal appeal" means a request to the MCO by a member or by a member's authorized representative or provider acting on behalf of the member and with the member's written consent for review of a contractor's adverse benefit determination, as defined in 42 CFR 438.400. The internal appeal is the only level of appeal with the MCO and must be exhausted by a member or deemed exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a state fair hearing with DMAS.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the Code of Virginia. Any health maintenance organization as defined in § 38.2-4300 of the Code of Virginia or health carrier that offers preferred provider contracts or policies as defined in § 38.2-3407 of the Code of Virginia or preferred provider subscription contracts as defined in § 38.2-4209 of the Code of Virginia shall be deemed to be offering one or more MCHIPs. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons to use providers who are directly or indirectly managed by, owned by, under contract with, or employed by the health carrier. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider network or set of provider networks.

Additionally, and in accordance with 42 CFR 438.2, "managed care organization" or "MCO" means an entity that has qualified to provide the services covered in the Medallion program to qualifying Medallion members as accessible in terms of timeliness, amount, duration, and scope as those services are to other Medicaid members within the area served, and that meets the solvency standards of 42 CFR 438.116.

"Mandatory managed care program" means the same as set forth in 42 CFR 438.54(b) and (d).

"Member" means a person eligible for Medicaid or Family Access to Medical Insurance Security who has been assigned to a Medicaid MCO.

"Network provider" means doctors, hospitals, or other health care providers who participate or contract with an MCO contractor and as a result agree to accept a mutually agreed upon sum or fee schedule as payment in full for covered services that are rendered to eligible participants.

"Newborn enrollment period" means the period from the child's date of birth plus the next two calendar months.

"PCP of record" means a primary care physician of record with whom the recipient has an established history, and such history is documented in the individual's records.

"Reconsideration" means a provider's request to the MCO for review of an adverse benefit determination. The MCO's reconsideration decision is a prerequisite to a provider's filing of an appeal, as provided for in 12VAC30-20-500 through 12VAC30-20-560, to DMAS Appeals Division.

"Rural exception" means a rural area designated in the § 1915(b) managed care waiver, pursuant to § 1932(a)(3)(B) of the Social Security Act and 42 CFR 438.52(b) and recognized by the Centers for Medicare and Medicaid Services, wherein qualifying mandatory managed care members are mandated to enroll in the one available contracted MCO.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396.

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 6, eff. January 7, 1998; Volume 14, Issue 18, eff. July 1, 1998; Volume 15, Issue 18, eff. July 1, 1999; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 29, Issue 2, eff. October 25, 2012; Volume 30, Issue 6, eff. January 2, 2014; Volume 30, Issue 7, eff. January 2, 2014; Volume 30, Issue 12, eff. March 28, 2014; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

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