GENERAL PROVISIONS
§ 301.301. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Contract—An arrangement between an HMO and a risk-bearing IDS, whereby the IDS is obligated to perform marketing, enrollment, administrative or similar functions. Administrative functions do not include quality assurance, utilization review, credentialing, provider relations or related functions.
Examination Law—Sections 901—1013 of The Insurance Company Law of 1921 (40 P. S. § § 323.1—324.13).
HMO—Health Maintenance Organization—An organized system which combines the delivery and financing of health care and the provision of basic health services to voluntarily enrolled members for a fixed prepaid fee, and is required to obtain a certificate of authority in accordance with applicable statutes and regulations (See sections 4 and 5.1 of the act (40 P. S. § § 1554 and 1555.1) and § § 301.41 and 301.42 (relating to prohibition against uncertified HMOs, and content of application for certificate of authority).
IDS—Integrated Delivery System—A partnership, association, corporation or other legal entity which enters into a contractual arrangement with an HMO; employs or has contracts with providers (participating providers); and agrees under its arrangements with an HMO, to provide or arrange for the provision of a defined set of health care services to HMO members covered under an HMO benefits contract principally through its participating providers, assumes under the arrangements some responsibility for conduct, in conjunction with the HMO and under compliance monitoring of the HMO, of quality assurance, utilization review, credentialing, provider relations, or related functions, may perform claims processing and other functions and which assumes to some extent, through capitation reimbursement or other risk-sharing arrangements, the financial risk for provision of these services to HMO members.
Provider—A ‘‘health care facility’’ or ‘‘health care provider’’ as those terms are defined under section 802(a) of the Health Care Facilities Act (35 P. S. § 448.802(a)), a mental health facility licensed by the Department of Public Welfare, or an individual licensed by the Commonwealth to practice a profession involved in the healing arts. The term includes hospitals, mental health treatment facilities, drug and alcohol treatment facilities, physicians, dentists, podiatrists, psychologists, nurses, physician assistants, certified registered nurse practitioners, physical therapists, chiropractors, optometrists and pharmacists.
Risk—The possibility of financial loss associated with contracts to perform a defined set of health care services for a predetermined portion of premium dollars.
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