W. Va. Code R. § 114-50-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-50-2 - Definitions

Terms not defined in this rule shall have the meanings given in W. Va. Code '33-25A-1 et seq. As used in this legislative rule:

2.1. "Acute Emergency Medical Service" means emergency medical services rendered in response to a request by an enrollee or a person acting on behalf of an enrollee, through "911," a community dispatcher or otherwise, either with the enrollee's permission or without the enrollee's permission if the enrollee is incapacitated, where:

a. there has been no precertification or preauthorization for the services by the health maintenance organization;

b. the emergency medical services were not scheduled in advance; and

c. the person making the request for emergency medical services does so in response to what the person perceives to be an emergency situation.

2.2. "Commissioner" means the Insurance Commissioner of the State of West Virginia.

2.3. "Covered Acute Emergency Medical Services" means acute emergency medical services for which a health maintenance organization is obligated to pay under the health maintenance organization contract with an enrollee.

2.4. "Covered Non-Acute Emergency Medical Services" means non-acute emergency medical services for which a health maintenance organization is obligated to pay under the health maintenance organization's contract with an enrollee.

2.5. "Emergency Medical Services" means acute emergency medical services and non-acute emergency medical services rendered to an enrollee of a health maintenance organization by an emergency medical service provider within the scope of its operations as an emergency medical service provider.

2.6. "Emergency Medical Service Provider" means an entity legally operating as an "emergency medical service provider" as that term is defined in W. Va. Code '16-4C-3.

2.7. "Emergency Situation" means a situation where the provision of emergency medical services is necessary to evaluate and or treat a medical condition manifesting itself by the sudden and at the time, unexpected onset of symptoms that require immediate medical attention and for which failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction to any bodily organ or part.

2.8. "Incapacitated" means a person who is unable for medical reasons to request or give consent to or receive emergency medical services.

2.9. "Non-Acute Emergency Medical Services" means emergency medical services other than acute emergency medical services including, but not limited to, scheduled transportation services provided by an emergency medical service provider.

2.10. "Noncovered Acute Emergency Medical Services" means acute emergency medical services for which a health maintenance organization is not obligated to pay under its contract with an enrollee.

2.11. "Noncovered Non-Acute Emergency Medical Services" means non-acute emergency medical services for which a health maintenance organization is not obligated to pay under its contract with an enrollee.

2.12. "Nonparticipating Provider" or "Noncontracting Provider" means a provider that has not entered into a contract with a health maintenance organization to provide health care services to enrollees of the health maintenance organization.

2.13. "Participating Provider" means a provider that has entered into a contract with a health maintenance organization to provide health care services to enrollees of the health maintenance organization.

W. Va. Code R. § 114-50-2