Terms Used In Montana Code > Title 33 > Chapter 36 - Managed Care Plan Network Adequacy and Quality Assurance

• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Closed plan: means a managed care plan that requires covered persons to use only participating providers under the terms of the managed care plan. See Montana Code 33-36-103
• Combination plan: means an open plan with a closed component. See Montana Code 33-36-103
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Covered benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Montana Code 33-36-103
• Covered person: means a policyholder, subscriber, or enrollee or other individual participating in a health benefit plan. See Montana Code 33-36-103
• Emergency medical condition: means a condition manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in any of the following:

  (a)the covered person's health would be in serious jeopardy;

  (b)the covered person's bodily functions would be seriously impaired; or

  (c)a bodily organ or part would be seriously damaged. See Montana Code 33-36-103

• Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Montana Code 33-36-103
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Facility: means an institution providing health care services or a health care setting, including but not limited to a hospital, medical assistance facility, critical access hospital, or rural emergency hospital, as those terms are defined in 50-5-101, or other licensed inpatient center, an outpatient center for surgical services, a treatment center, a skilled nursing center, a residential treatment center, a diagnostic laboratory, a diagnostic imaging center, or a rehabilitation or other therapeutic health setting. See Montana Code 33-36-103
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health benefit plan: means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Montana Code 33-36-103
• Health care professional: means a physician or other health care practitioner licensed, accredited, or certified pursuant to the laws of this state to perform specified health care services consistent with state law. See Montana Code 33-36-103
• Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Montana Code 33-36-103
• Health carrier: means an entity subject to the insurance laws and rules of this state that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a disability insurer, health maintenance organization, or health service corporation or another entity providing a health benefit plan. See Montana Code 33-36-103
• Intermediary: means a person authorized to negotiate, execute, and be a party to a contract between a health carrier and a provider or between a health carrier and a network. See Montana Code 33-36-103
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Managed care plan: means a health benefit plan that either requires or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by a health carrier, but not preferred provider organizations or other provider networks operated in a fee-for-service indemnity environment. See Montana Code 33-36-103
• Medically necessary: means services, medicines, or supplies that are necessary and appropriate for the diagnosis or treatment of a covered person's illness, injury, or medical condition according to accepted standards of medical practice and that are not provided only as a convenience. See Montana Code 33-36-103
• Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
• Open plan: means a managed care plan other than a closed plan that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan. See Montana Code 33-36-103
• Participating provider: means a provider who, under a contract with a health carrier or with the health carrier's contractor, subcontractor, or intermediary, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier. See Montana Code 33-36-103
• Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
• Primary care professional: means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person and who may be required by the health carrier to initiate a referral for specialty care and to maintain supervision of health care services rendered to the covered person. See Montana Code 33-36-103
• Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
• provider: means a health care professional or a facility. See Montana Code 33-36-103
• Quality assessment: means the measurement and evaluation of the quality and outcomes of medical care provided to individuals, groups, or populations. See Montana Code 33-36-103
• Quality assurance: means quality assessment and quality improvement. See Montana Code 33-36-103
• Quality improvement: means an effort to improve the processes and outcomes related to the provision of health care services within a health plan. See Montana Code 33-36-103
• Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. ^{Source: FDIC}
• Subpoena: A command to a witness to appear and give testimony.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Writing: includes printing. See Montana Code 1-1-203