Cuáles son los temas prioritarios a futuro.

other participating health plans, to be used for quality improvement purposes. The studies include four phases and may occur within a 24 month time frame. 99. Quality Improvement System (QIS) means the systematic activities to monitor

and evaluate the medical care delivered to Members according to the standards set forth in regulations and contract language. Contractor must have processes in place, which measure the effectiveness of care, identify problems, and

implement improvement on a continuing basis.

100. Quality of Care means the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are

consistent with current professional knowledge.

101. Quality Indicators means measurable variables relating to a specific clinic or health services delivery area which are reviewed over a period of time to screen delivered health care and to monitor the process or outcome of care delivered in that clinical area.

102. Rural Health Clinic (RHC) means an entity defined in Title 22 CCR Section 51115.5.

103. Safety-Net Provider means any provider of comprehensive primary care or acute hospital inpatient services that provides these services to a significant total number of Medi-Cal and charity and/or medically indigent patients in relation to the total number of patients served by the provider. Examples of safety-net providers include Federally Qualified Health Centers; governmentally operated health systems; community health centers; Rural and Indian Health Programs; disproportionate share hospitals; and public, university, rural, and children's hospitals.

Contract Number Exhibit E, Attachment 1

DEFINITIONS

104. Seniors and Persons with Disabilities (SPD) means Medi-Cal beneficiaries who fall under specific Aged and Disabled aid codes as defined by the

department (See Eligible Beneficiary).

105. Service Area means the county or counties that the Contractor is approved to operate in under the terms of this Contract. A Service Area may have

designated zip Codes (under the U.S. Postal Service) within a county that are approved by DHCS to operate under the terms of this Contract.

106. Service Authorization Request means a Member’s request for the provision of a Covered Service.

107. Service Location means any location at which a Member obtains any health care service provided by the Contractor under the terms of this Contract. 108. Skilled Nursing Facility (SNF) means, as defined in Title 22 CCR Section

51121(a), any institution, place, building, or agency which is licensed as a SNF by DHCS or is a distinct part or unit of a hospital, meets the standard specified in Section 51215 of these regulations (except that the distinct part of a hospital does not need to be licensed as a SNF) and has been certified by DHCS for participation as a SNF in the Medi-Cal program. Section 51121(b) further defines the term "Skilled Nursing Facility" as including terms "skilled nursing home", "convalescent hospital", "nursing home," or "nursing facility."

109. Specialty Care Center means a center that is accredited or designated by the State or federal government, or by a voluntary national health organization, as having special expertise in treating the life-threatening disease or condition or degenerative and disabling disease or condition for which it is accredited or designated.

110. Specialty Mental Health Provider means a person or entity who is licensed, certified or otherwise recognized or authorized under State law governing the healing arts and who meets the standards for participation in the Medi-Cal program to provide Specialty Mental Health Services.

111. Specialty Mental Health Service means:

A. Rehabilitative services, which includes mental health services, medication support services, day treatment intensive, day rehabilitation, crisis

intervention, crisis stabilization, adult residential treatment services, crisis residential services, and psychiatric health facility services;

B. Psychiatric inpatient hospital services; C. Targeted Case Management;

Contract Number Exhibit E, Attachment 1

DEFINITIONS

D. Psychiatrist services; E. Psychologist services; and

F. EPSDT supplemental Specialty Mental Health Services.

112. Standing Referral means a referral by a Primary Care Physician to a specialist for more than one visit to the specialist, as indicated in the treatment plan, if any, without the primary care physician having to provide a specific referral for each visit.

113. State means the State of California.

114. State Supported Services means those services that are provided under a different contract between the Contractor and the Department.

115. Subacute Care means, as defined in Title 22 CCR Section 51124.5, a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a SNF.

116. Subcontract means a written agreement entered into by the Contractor with any of the following:

A. A provider of health care services who agrees to furnish Covered Services to Members.

B. Any other organization or person(s) who agree(s) to perform any

administrative function or service for the Contractor specifically related to fulfilling the Contractor's obligations to DHCS under the terms of this Contract.

117. Sub-Subcontractor means any party to an agreement with a subcontractor descending from and subordinate to a Subcontract, which is entered into for the purpose of providing any goods or services connected with the obligations under this Contract.

118. Supplemental Security Income (SSI) means the program authorized by Title XVI of the Social Security Act for aged, blind, and disabled persons.

119. Targeted Case Management (TCM) means services which assist Medi-Cal Members within specified target groups to gain access to needed medical, social,

Contract Number Exhibit E, Attachment 1

DEFINITIONS

as a Medi-Cal benefit as a discrete service, as well as through State or local government entities and their contractors.

120. Third Party Tort Liability (TPTL) means the responsibility of an individual or entity other than Contractor or the Member for the payment of claims for injuries or trauma sustained by a Member. This responsibility may be contractual, a legal obligation, or as a result of, or the fault or negligence of, third parties (e.g., auto accidents or other personal injury casualty claims or Workers' Compensation appeals).

121. Traditional Provider means any physician who has delivered services to Medi- Cal beneficiaries within the last six months either through FFS Medi-Cal or a Medi-Cal Managed Care plan. The term includes physician and hospital

providers only, either profit or non-profit entities, publicly or non-publicly owned and operated.

122. Urgent Care means services required to prevent serious deterioration of health following the onset of an unforeseen condition or injury (i.e., sore throats, fever, minor lacerations, and some broken bones).

123. Utilization Review means the process of evaluating the necessity,

appropriateness, and efficiency of the use of medical services, procedures and Facilities.

124. Vaccines for Children (VFC) Program means the Federally funded program that provides free vaccines for eligible children (including all Medi-Cal eligible children age 18 or younger) and distributes immunization updates and related information to participating providers. Providers contracting with the Contractor are eligible to participate in this program.

125. Working day(s) mean State calendar (State Appointment Calendar, Standard 101) working day(s).

Contract Number Exhibit E, Attachment 2

PROGRAM TERMS AND CONDITIONS