Section He-W 506.03 - Definitions(a) "Action" means a managed care organization (MCO) or DO activity including, but not limited to, the following activities identified in the definition of "adverse benefit determination" in 42 CFR 438.400(b): (1) The denial or limited authorization of a requested service, including the type or level of service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;(2) The reduction, suspension, or termination of a previously authorized service;(3) The denial, in whole or in part, of payment for a service except when denial for payment for a service is solely because the claim does not meet the definition of a "clean claim";(4) The failure to provide services in a timely manner, as described in the contracts between the department and the MCO or the DO;(5) The failure of an MCO or DO to act within the timeframes required for a service authorization, disposition of a grievance, standard resolution of an appeal, or expedited resolution of an appeal, as described in the contracts between the department and the MCO or the DO; or(6) The denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, or other enrollee financial liabilities.(b) "Alternative Benefit Plan (ABP) services" means the secretary-approved coverage described in section 1937 of the Social Security Act and which aligns with and includes the traditional medicaid state plan services.(c) "Appeal" means a request to the MCO or DO for the review of any action taken by the MCO or DO.(d) "Clean claim" means a claim that does not have any defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment.(e) "Dental organization (DO)" means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid dental services.(f) "Department" means the New Hampshire department of health and human services.(g) "Fair hearing" means an administrative appeal under He-C 200.(h) "Fee-for-service" means the reimbursement method used by the department: (1) For all services to recipients who are not enrolled in managed care; and(2) For those services excluded from managed care for all recipients.(i) "Granite Advantage Health Care Program (Granite Advantage)" means the granite advantage health care program established under RSA 126-AA, which authorizes medical assistance for individuals described in 42 U.S.C § 1396a(a)(10)(A)(i) (VIII).(j) "Grievance" means an expression of dissatisfaction about any matter, other than an action, that is communicated to the MCO or DO, such as with regard to the quality of care or services provided, and aspects of interpersonal interactions with the MCO or DO employees.(k) "Managed care organization (MCO)" means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid health care services.(l) "MCO or DO grievance system" means the system through which members can complain, express dissatisfaction, or challenge an action made by the MCO or DO, including: (1) An MCO or DO grievance process;(2) An MCO or DO appeal process; and(3) Access to the department's fair hearing process after (l)(2) above has been exhausted.(m) "Medicaid" means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.(n) "Member" means a recipient who has selected or who has been passively enrolled into an MCO or DO.(o) "Recipient" means any individual who is eligible for and is receiving medical assistance under the New Hampshire medicaid program.(p) "Title XIX" means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.(q) "Title XXI" means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.N.H. Admin. Code § He-W 506.03
#10410, eff 9-13-13; amd by #10631, eff 7-1-14
Amended by Volume XXXV Number 45, Filed November 12, 2015, Proposed by #10965, Effective 11/1/2015, Expires11/1/2025.Amended by Volume XXXVIII Number 23, Filed June 7, 2018, Proposed by #12537, Effective 5/24/2018, Expires 5/24/2028.Amended by Volume XLII Number 45, Filed November 10, 2022, Proposed by #13474, Effective 10/25/2022, Expires 10/25/2032.Amended by Number 28, Filed July 13, 2023, Proposed by #13670, Effective 6/22/2023, Expires 6/22/2033.