A. Act. Arkansas Act 454 of 1975, as amended.

B. Administrator. The person responsible for the management of the Health Maintenance Organization (HMO).

C. Case Management. An activity which assists individuals in gaining and coordinating access to necessary care and services appropriate to the needs of the individual. It is the facilitation of health services including either medical or ancillary health care resources for efficient and medically appropriate ends for enrolled members. The activity is designed to achieve the optimal patient outcome in the most cost-effective manner.

D. Certificate of Authority. A document issued by the Commissioner of the Arkansas Insurance Department permitting one to establish, maintain, and operate an HMO.

E. Commissioner. The Commissioner of the Arkansas Insurance Department.

F. Consumer. Solely for the purpose of the composition of the Governing Body/Oversight Committee, is any person other than a person (i)whose occupation involves, or before retirement involved, the administration of health activities or the providing of Health Care Services, (ii) who is, or ever was, employed by a health care facility as a licensed Health Professional, or (iii) who has, or ever had, a direct, substantial financial or managerial interest in the rendering of Health Care Services other than the payment of a reasonable expense reimbursement or compensation as a member of the board of an HMO.

G. Credentials. Certificates, diplomas, licenses, or other written documentation which establish proof of training, education, and experience in a field of expertise.

H. Department. The Arkansas Department of Health.

I. Director. The Director of the Arkansas Department of Health.

J. Emergency Health Care Services. Those Health Care Services which shall be available on a twenty-four (24) hours per day, seven (7) days per week basis to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain that would lead a prudent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in (i) placing the patient's health in serious jeopardy; (ii)serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.

K. Enrollee. An individual who is contractually entitled to receive covered Health Care Services from an HMO.

L. Evidence of Coverage. Any certificate, agreement, contract, identification card, or document issued to an Enrollee setting out the coverage to which he/she is entitled.

M. Health Care Plan. Any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any Health Care Services, and at least part of such arrangement consists of arranging for or the provision of Health Care Services, as distinguished from mere indemnification against the cost of such services, on a prepaid basis through insurance or otherwise.

N. Health Care Services. Any services included in the furnishing to any individual of medical or dental care, or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services or goods for the purpose of preventing, alleviating, curing, or healing human illness or injury.

O. Health Maintenance Organization (HMO). Any person who undertakes to provide or arrange for one or more Health Care Plans under the Act.

P. Health Professional. Individuals engaged in the delivery of Health Care Services as are or may be designated under U. S. Public Law 93-222, same being the Health Maintenance Organization Act of 1973 or any amendment thereto or regulation adopted thereunder.

Q. Hospital. As defined in the currently certified Rules and Regulations for Hospitals and Related Institutions in Arkansas as promulgated by the Arkansas Department of Health.

R. Inpatient Medical Care. Shall include, but not be limited to medical and surgical care received in a hospital or skilled nursing environment.

S. Limited Benefit HMO. An HMO that elects to provide or arrange for the provision of one (1) Health Care Service (e.g. dental, mental health, vision, etc.) to its Enrollees. The limited benefit shall be the only type of benefit offered to Enrollees under its Health Care Plan. An HMO certified in this category shall comply with all applicable provisions of these Rules and Regulations.

T. Medical Director. A physician (M.D. or D.O.) licensed to practice in the State of Arkansas. The Medical Director shall provide medical direction of the HMO's health care activities and consultation for and medical supervision of the medical staff of a Staff Model HMO.

U. Outpatient Services. Those covered services which may be rendered in, but are not limited to, clinics, home health services, hospices, kidney dialysis centers, private offices, pharmacies, and hospital-based outpatient services, as a minimum, and may also include, but are not limited to outpatient surgery centers and radiation therapy centers.

V. Peer Review. A review of the decisions and actions by one's peers within the organizational structure of the HMO.

W. Person. Any natural or artificial person including, but not limited to individuals, partnerships, associations, trusts, or corporations.

X. Pharmacy. A facility which possesses the appropriate permit from the Arkansas State Board of Pharmacy.

Y. Physical Plant. The physical building, equipment, and fixtures of a Staff Model HMO. It shall include, but not be limited to environment, electrical services, plumbing services, water supply and disposal, infection control, and waste disposal.

Z. Preventive Health Services. Services designed to maintain an individual in optimum health and to prevent unnecessary injury, illness, or disability.

AA. Primary Care Physician. A physician who supervises, coordinates, and provides initial and basic care to Enrollees; initiates their referral for specialty care; and maintains the continuity of patient care. The care of episodic illness alone does not constitute the role of a Primary Care Physician.

BB. Private Review Agency. Any entity certified by the Department under Act 537 of 1989 performing utilization review that is either affiliated with, under contract with, or acting on behalf of an Arkansas business entity or a third party that provides or administers hospital and medical benefits to citizens of Arkansas including an HMO or any entity offering health insurance policies, contracts, or benefits in this State including a health insurer, non-profit health service plan, health insurance organization, preferred Provider organization, or managed care organization.

CC. Provider. Any person who is licensed in this State to furnish Health Care Services as a Health Professional.

DD. Quality Assurance Systems. The planned and systematic management actions which assure the consistent rendering of high quality Health Care Services through the use of monitoring techniques.

EE. Retrospective Review. A mechanism to review medical necessity and appropriateness of medical services through compilation and analysis of data after medical care is rendered which includes, but is not limited to the comparison of Provider practice patterns with parameters established by the utilization review committee, recommendations of changes in Provider practice patterns based on analysis and review, and analyzation of care to Enrollees.

FF. Service Area. The geographic area as defined by county boundaries authorized by the Certificate of Authority.

GG. Staff Model HMO. An HMO that provides any of its Health Care Services through physicians and other Health Professionals who work in centralized health centers as salaried or paid employees (staff) of the HMO and where the Health Care Service is provided at a health center owned or leased by the HMO. It shall include a described Physical Plant.

HH. Utilization Review Plan. A system for the formal assessment of medical necessity, efficiency, and/or appropriateness of Health Care Services and treatment plans on a prospective, concurrent, or retrospective basis.