W. Va. Code R. § 114-53-2

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

Section 114-53-2 - Definitions

2.1. "Accountability" means the responsibility of a department or individual for achieving defined goals.

2.2. "Appropriateness" means the extent to which a particular procedure, treatment, test or service is clearly indicated, not excessive, adequate in quantity and provided in the setting best suited to the patient's/member's needs.

2.3. "Commissioner" means the West Virginia Insurance Commissioner.

2.4. "Clinician" means a state-recognized provider including but not limited to physicians, psychologists and psychiatrists who specialize in clinical studies or practice.

2.5. "Credentialing" means the process by which a health maintenance organization authorizes, contracts with or employs clinicians, who are licensed to practice independently, to provide services to its members.

2.6 "DEA" means Drug Enforcement Administration, the Federal agency that issues licenses to prescribe and dispense scheduled drugs.

2.7. "Delegation" or "delegated" means the formal process by which a health maintenance organization gives a contractor the authority to perform certain functions on its behalf, such as credentialing, utilization review and quality assurance. A health maintenance organization can delegate the authority to perform a function but cannot delegate the responsibility for assuring the function is performed properly.

2.8. "Governing body" means an individual, group or agency with the ultimate authority and responsibility for the overall operation of the organization.

2.9 "Health care services" means any services or goods included in the furnishing to any individual of medical, mental or dental care, or hospitalization, osteopathic services, chiropractic services, podiatric services, home health, health education, or rehabilitation, as well as the furnishing to any person of any and all other services or goods for the purpose of preventing, alleviating, curing or healing human illness or injury.

2.10. "Health maintenance organization" or "HMO" means a public or private organization which provides, or otherwise makes available to enrollees, health care services, including at a minimum basic health care services, which:

a. Receives premiums for the provision of basic health care services to enrollees on a prepaid per capita or prepaid aggregate fixed sum basis, excluding copayments;

b. Primarily provides physicians' services:

1. Directly through physicians who are either employees or partners of the organization;

2. Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice arrangement; or

3. Through some combination of paragraphs one and two of this subdivision;

c. Assures the availability, accessibility and quality including appropriate utilization of the health care services that it provides or makes available through clearly identifiable focal points of legal and administrative responsibility; and

d. Offers services through an organized delivery system, in which a primary care physician is designated for each subscriber upon enrollment. The primary care physician is responsible for coordinating the health care of the subscriber and is responsible for referring the subscriber to other providers when necessary: Provided, that when dental care is provided by the health maintenance organization the dentist selected by the subscriber from the list provided by the health maintenance organization shall coordinate the covered dental care of the subscriber, as approved by the primary care physician or the health maintenance organization.

2.11. "Medical record" means the record in which clinical information relating to the provision of physical, social and mental health services is recorded and stored.

2.12. "Member," "subscriber" or "enrollee" means an individual who has been voluntarily enrolled in a health maintenance organization, including individuals on whose behalf a contractual arrangement has been entered into with a health maintenance organization to receive health care services.

2.13. "Oversight" means the monitoring and direction of a set of activities by individuals responsible for the execution of the activities resulting in the achievement of desired outcomes.

2.14. "Practice guidelines" or "protocols" means systematically developed statements to assist patient and practitioner decisions about appropriate health care for specific clinical circumstances. Practice guidelines are usually based on such authoritative sources as clinical literature and expert consensus.

2.15. "Provider" means any physician, hospital, or other person or organization which is licensed or otherwise authorized in this state to furnish health care services.

2.16. "Quality assurance" means an ongoing program designed to objectively and systematically monitor and evaluate the quality and appropriateness of the enrollee's care, pursue opportunities to improve the enrollee's care and to resolve identified problems at the prevailing professional standard of care.

2.17. "Quality assurance work plan" means an annual plan that describes with timeliness the specific planned quality assurance activities that will be carried out within the quality assurance program.

2.18. "Quality of care" means the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

W. Va. Code R. § 114-53-2