18 Del. Admin. Code § 1403-2.0
The following words and terms, when used in this regulation, should have the following meaning unless the context clearly indicates otherwise:
"Adverse determination" means a decision by an MCO to deny (in whole or in part), reduce, limit or terminate benefits under a health care contract.
"Appeal" means a request for external review of an MCO's determination resulting in a denial, termination or other limitations of covered health services based on medical necessity or appropriateness of services
"Appropriateness of services" means an appeal classification for adverse determinations that are made based on identification of treatment as cosmetic, investigational, experimental or not an appropriate or preferred treatment method or setting for the condition for which treatment is sought.
"Balance billing" means a health care provider's demand that a patient pay a greater amount for a given service than the amount the individual's insurer, managed care organization, or health service corporation has paid or will pay for the service.
"Basic Health Services" means a range of health care services, including at least the following:
"Carrier" means any entity that provides health insurance in this State. Carrier includes an insurance company, health service corporation, managed care organization and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. Carrier also includes any third-party administrator or other entity that adjusts, administers or settles claims in connection with health insurance.
"Certificate of Authority" means the authorization by the Department to operate the MCO. This certificate shall be deemed to be a license to operate such an organization.
"Chief Executive Officer" means the individual employed to manage and direct the activities of the MCO.
"Covered health services" means services that are included in the enrollee's health care contract with the carrier.
"Covered Person": see "Enrollee."
"Department" means the Delaware Department of Insurance.
"Emergency care" means health care items or services furnished or required to evaluate or treat an emergency medical condition.
"Emergency medical condition" means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity including, but not limited to, severe pain, that a prudent layperson, possessing an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
"Enrollee" means an individual and/or family who has entered into a contractual arrangement, or on whose behalf a contractual arrangement has been entered into with the MCO, under which the MCO assumes the responsibility to provide to such person(s) coverage for basic health services and such supplemental health services as are enumerated in the health care contract.
"Geographically accessible" means a location no greater than 30 miles or 40 minutes driving time from 90% of enrollees within MCO's geographic service area.
"Geographic service area" means the stated primary geographical area served by an MCO. The primary area served shall be a radius of not more than 20 miles or more than 30 minutes driving time from a primary care office operated or contracted by the MCO.
"Grievance" means a request by an enrollee that an MCO review an adverse determination by means of the MCO's internal review process.
"Health care contract" means any agreement between an MCO and an enrollee or group plan which sets forth the services to be supplied to the enrollee in exchange for payments made by the enrollee or group plan.
"Health care professional" means an individual engaged in the delivery of health care services as licensed or certified by the State of Delaware.
"Health care services" means 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.
"Independent Health Care Appeals Program" means a program administered by the Department which provides for a review by an Independent Utilization Review Organization.
"Independent Utilization Review Organization (IURO)" means an entity that conducts independent external reviews of a carrier's determinations resulting in a denial, termination, or other limitation of covered health care services based on medical necessity or appropriateness of services.
"Intermediary" means a person authorized to negotiate and execute provider contracts with MCOs on behalf of health care providers or on behalf of a network.
"Internal review process" means a procedure established by an MCO for internal review of an adverse determination.
"Level 1 trauma center" means a regional resource trauma center that has the capability of providing leadership and comprehensive, definitive care for every aspect of injury from prevention through rehabilitation.
"Level 2 trauma center" means a regional trauma center with the capability to provide initial care for all trauma patients. Most patients would continue to be cared for in this center; there may be some complex cases which would require transfer for the depth of services of a regional Level 1 or specialty center.
"Managed Care Organization (MCO)" means a public or private organization, organized under the laws of any state, which:
An MCO may also arrange for health care services on a prepayment or other financial basis.
"Medical necessity" means providing of covered health services or products that a prudent physician would provide to a patient for the purpose of diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is:
"Network" means the participating providers delivering services to enrollees.
"Office" means any facility where enrollees receive primary care or other health care services.
"Out of area coverage" means health care services provided outside the MCO's geographic service areas with appropriate limitations and guidelines acceptable to the Department. At a minimum, such coverage must include emergency care.
"Participating provider" means a provider who, under a contract with the MCO or with its contractor or sub contractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, co-payments or deductibles, directly or indirectly from the MCO.
"Premium" means payment(s) called for in the health care contract which must be:
"Primary care physician (PCP)" means a participating physician chosen by the enrollee and designated by the MCO to supervise, coordinate, or provide initial care or continuing care to an enrollee, and who may be required by the MCO to initiate a referral for specialty care and maintain supervision of health care services rendered to the enrollee.
"Provider" means a health care professional or facility.
"Staff Model MCO" means an MCO in which physicians are employed directly by the MCO or in which the MCO directly operates facilities which provide health care services to enrollees.
"Tertiary services" means health care services provided for the intensive treatment of critically ill patients who require extraordinary care on a concentrated basis in special diagnostic categories (e.g., burns, cardiovascular, neonatal, pediatric, oncology, transplants, etc.).
"Utilization review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, efficacy, and/or efficiency of, health care services, procedures or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review.
18 Del. Admin. Code § 1403-2.0