Definitions

All terms contained in these rules shall have the same meaning as defined in the Health Maintenance Organization Act of 1986, as amended. See T.C.A. § 56-32-202. As used in these rules, unless the context dictates otherwise, the definitions are as follows: (1) Basic health care services. All those health services which a defined population might reasonably require in order to be in good health, including as a minimum, but not limited to, emergency care, inpatient hospital and physician care, ambulatory physician care and outpatient preventive medical services. (2) Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services. CMS runs the Medicare and Medicaid programs which are national health care programs that benefit about seventy-five (75) million Americans. With the Health Resources and Services Administration, CMS runs the State Children’s Health Insurance Program (SCHIP), a program that is expected to cover many of the approximately ten (10) million uninsured children in the United States. (3) Certificate of Authority (COA or license). The license issued by the Tennessee Department of Commerce and Insurance that permits a person or organization to establish and operate a health maintenance organization. (4) Clean claim. A claim received by an HMO for adjudication, and which requires no further information, adjustment or alteration by the provider of the services in order to be processed and paid by the health insurer. A claim is clean if it has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this section. (5) Department. The Tennessee Department of Health (TDH). (6) Department of Commerce and Insurance. The Tennessee Department of Commerce and Insurance (TDCI). (7) Department of Health. The Tennessee Department of Health (TDH). (8) Emergency Care. Health services and care provided for a medical condition (illness, disease, accident, or injury) 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 potentially result in (a) placing the person’s health in serious jeopardy, (b) serious impairment to bodily functions, or (c) dysfunction of a bodily organ or part. (9) Enrollee. An individual who is enrolled in a health maintenance organization. STANDARDS FOR QUALITY OF CARE FOR HEALTH CHAPTER 0720-34 MAINTENANCE ORGANIZATIONS (10) Governing Body. The board of directors or other person or entity that governs the operation of the health maintenance organization in the State of Tennessee. (11) Grievance. A written complaint as defined in T.C.A. § 56-32-210(a)(2)(A). A grievance usually expresses dissatisfaction with a decision or action of the health maintenance organization or its providers (e.g., coverage decisions, pre-authorization requests, quality of care, accessibility of care) and seeks resolution. (12) Health care services. Any services included in the furnishing to any individual of medical or dental care, or hospitalization, or incidental to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability. (13) Health Maintenance Organization (HMO). Any person or organization that undertakes to provide or arrange for basic health care services to enrollees on a prepaid basis. The person or organization may provide physician services directly through physician employees or under arrangements with individual physicians or a group or groups of physicians. The person or organization may also provide or arrange for other health care services on a prepayment or other financial basis. An HMO may also provide or arrange for additional health care services. (14) Member. An individual who is enrolled in a health maintenance organization (i.e., an enrollee). (15) National Committee for Quality Assurance (NCQA). An independent 501(c)(3) non-profit organization whose mission is to improve health care quality.