Ariz. Admin. Code § 20-6-1902
Current through Register Vol. 30, No. 50, December 13, 2024
Section R20-6-1902 - [Effective 1/5/2025] Definitions In addition to the definitions provided in A.R.S. § 20-1051, the following terms apply to this Article:
1. "Access" or "accessibility" means the extent to which an enrollee can obtain timely covered services from a contracted provider at the appropriate level of care, and appropriate location.2. "Adult" means an enrollee in the age group the HCSO has designated for an adult.3. "Adult PCP" means a primary care provider practicing in any specialty the HCSO designates as adult primary care.4. "Ancillary provider" means a provider of laboratory, radiology, pharmacy or rehabilitative services, physical therapy, occupational therapy, or speech therapy, home health services, dialysis, and durable medical equipment or medical supplies dispensed by order or prescription of a provider with the appropriate prescribing authority.5. "Available" or "availability" means the extent to which the plan has contracted providers of the appropriate type and numbers at geographic locations to afford members access to timely covered services.6. "Chief executive officer" or "CEO" means the person who has the authority and responsibility for the operation of the health care services organization according to applicable legal requirements and policies approved by the governing authority.7. "Child" means an enrollee in the age group the HCSO has designated for children.8. "Contracted" means a provider has a current written agreement or an employment arrangement with an HCSO to provide covered services to an enrollee, or a current written agreement or an employment arrangement with a contracted provider to provide covered services to an enrollee.9. "Covered" or "covered services" means the health care services described as covered benefits in the HCSO's evidence of coverage.10. "Day" means calendar day unless specified otherwise.11. "Department" means the Department of Insurance and Financial Institutions.12. "Director" has the meaning stated at A.R.S. § 20-102.13. "Effective process" means written policies and procedures that:a. Outline the steps that the HCSO implements and consistently follows internally,b. The HCSO subjects to internal quality improvement, andc. The HCSO communicates to providers when established or changed.14. "Emergency services" has the meaning stated at A.R.S. § 20-2801(3). 15. "Facility" means an institution that is licensed or authorized to furnish health care services in this state, including general hospitals, special hospitals, residential treatment centers, residential rehabilitation centers, skilled nursing facilities, urgent care centers, and ambulatory surgical treatment centers.16. "Governing authority" means a person or body such as a board of trustees or board of directors in whom the ultimate authority and responsibility for the direction of the HCSO is vested.17. "HCSO" means a health care services organization. 18. "High profile" means one of no fewer than four specialties designated by the HCSO, and does not include obstetrics-gynecology. An HCSO may designate a specialty as high profile on the basis of high volume or other basis the HCSO reasonably determines is directly related to providing covered services to a member.19. "Hospital" means a facility that provides inpatient care, medical services, and continuous nursing services for the diagnosis and treatment of patients.20. "Inpatient care" means the covered services that an enrollee who is admitted to a hospital receives for at least 24 consecutive hours.21. "Inpatient emergency care" means covered services that would be emergency services if provided in a licensed hospital emergency facility.22. "License" means documented authorization issued by the appropriate state of Arizona agency to operate a facility in Arizona, or to practice a health care profession in Arizona.23. "Medically necessary" has the meaning set forth in the HCSO's evidence of coverage.24. "Network" means the group of providers contracted with an HCSO to provide covered services to an enrollee covered under the HCSO's health benefit plan.25. "Network exception" means an enrollee receives covered services from a non-contracted provider either:a. Because there is no contracted provider accessible or available that can provide the enrollee timely covered services, orb. For any reason the HCSO determines it is in the enrollee's best interests to receive care from a non-contracted provider.26. "Non-contracted" means a provider that does not have a contract with an HCSO to provide services to an enrollee.27. "Normal business hours" means 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding state or national holidays.28. "Outpatient care" means covered services that an enrollee who is not an inpatient receives.29. "Pediatric primary care provider" means a physician or practitioner practicing in any specialty the HCSO designates as pediatric primary care.30. "Physician" means a licensed doctor of allopathic, chiropractic, optometric, osteopathic, or podiatric medicine.31. "Practitioner" means any individual other than a physician who is licensed to furnish health care services, including behavioral health care services, in this state.32. "Preventive care" means health maintenance care the HCSO provides or arranges to prevent illness and to improve the general health of an enrollee, including:c. Health evaluation and follow-up,d. Early disease detection,e. Screening tests appropriate for a person's age and gender, andf. Periodic health care examinations.33. "Primary care" means any specialty the HCSO designates as primary care.34. "Primary care physician" or "PCP" means a physician or practitioner practicing in a specialty the HCSO designates as primary care. 35. "Quality improvement" means an HCSO's system for assessing and improving the level of performance of key process and outcomes.36. "Routine care" means covered primary care for an enrollee's non-urgent, symptomatic condition.37. "Rural" means a zip code area with fewer than 1,000 persons per square mile as calculated annually by a population data gathering service designated by the Director.38. "Service area" means any geographic area designated by any HCSO and approved by the Director under A.R.S. § 20-1053(A)(11).39. "Special hospital" means a hospital that is licensed to provide hospital services within a specific area of medicine, or limits patient admission according to age, gender, type of disease, or medical condition.40. "Specialty" or "specialty care" means a specific area of medicine practiced by a physician or practitioner who has education, training, or qualifications in that specific area of medicine in addition to the education or qualifications required for the physician's or practitioner's license.41. "Specialty care provider" or "SCP" means a physician or practitioner who has education, training, or qualifications in a specialty, other than primary care, beyond the education or qualifications required for the license.42. "Suburban area" means any zip code area with 1,000-3,000 persons per square mile, as calculated annually by a population data gathering service designated by the Director.43. "Telemedicine" has the same meaning as "telehealth" found at A.R.S. § 20-1057(G).44. "Timely" means services are provided at the time when medically necessary.45. "Travel expenses" has the meaning set forth in writing by an HCSO.46. "Urban area" means a zip code with more than 3,000 persons per square mile as calculated annually by a population data gathering service designated by the Director.47. "Urgent care" means unscheduled services for an enrollee's condition that requires medical attention not amenable to scheduling in order to avoid a serious risk of harm.Ariz. Admin. Code § R20-6-1902
New Section made by exempt rulemaking at 7 A.A.R. 2769, effective July 1, 2001 (Supp. 01-2). Amended by final rulemaking at 11 A.A.R. 4861, effective December 31, 2005 (Supp. 05-4). Amended by final rulemaking at 30 A.A.R. 3519, effective 1/5/2025.