§108D-1. Definitions

The following definitions apply in this Chapter, unless the context clearly requires otherwise:

(1)        Applicant. - A provider of mental health, intellectual or developmental disabilities, and substance abuse services who is seeking to participate in the closed network of one or more local management entity/managed care organizations.

(2)        Closed network. - The network of providers that have contracted with a local management entity/managed care organization to furnish mental health, intellectual or developmental disabilities, and substance abuse services to enrollees.

(3)        Contested case hearing. - The hearing or hearings conducted at the Office of Administrative Hearings under G.S. 108D-15 to resolve a dispute between an enrollee and a local management entity/managed care organization about a managed care action.

(4)        Department. - The North Carolina Department of Health and Human Services.

(5)        Emergency medical condition. - As defined in 42 C.F.R. § 438.114.

(6)        Emergency services. - As defined in 42 C.F.R. § 438.114.

(7)        Enrollee. - A Medicaid beneficiary who is currently enrolled with a local management entity/managed care organization.

(8)        Local Management Entity or LME. - As defined in G.S. 122C-3(20b).

(9)        Local Management Entity/Managed Care Organization or LME/MCO. - As defined in G.S. 122C-3(20c).

(10)      Managed care action. - An action, as defined in 42 C.F.R. § 438.400(b).

(11)      Managed Care Organization or MCO. - As defined in 42 C.F.R. § 438.2.

(12)      Mental health, intellectual or developmental disabilities, and substance abuse services or MH/IDD/SA services. - Those mental health, intellectual or developmental disabilities, and substance abuse services covered under a contract in effect between the Department of Health and Human Services and a local management entity to operate a managed care organization or prepaid inpatient health plan (PIHP) under the 1915(b)/(c) Medicaid Waiver approved by the federal Centers for Medicare and Medicaid Services (CMS).

(13)      Network provider. - An appropriately credentialed provider of mental health, intellectual or developmental disabilities, and substance abuse services that has entered into a contract for participation in the closed network of one or more local management entity/managed care organizations.

(14)      Notice of managed care action. - The notice required by 42 C.F.R. § 438.404.

(15)      Notice of resolution. - The notice described in 42 C.F.R. § 438.408(e).

(16)      OAH. - The North Carolina Office of Administrative Hearings.

(17)      Prepaid Inpatient Health Plan or PIHP. - As defined in 42 C.F.R. § 438.2.

(18)      Provider of emergency services. - A provider that is qualified to furnish emergency services to evaluate or stabilize an enrollee's emergency medical condition.

(2013-397, s. 1.)