360-10.3 Definitions.
As used in this Subpart, unless expressly stated otherwise or unless the context of the
subject matter requires a different interpretation:
(a) Grievance procedure means a process established by a managed care
provider for receiving and promptly adjudicating any complaint which an MCP participant
submits to the managed care provider. All grievance procedures which are included as part
of a social services district's managed care plan, except for those which the Department
of Health has already approved under Article 44 of the Public Health Law, are subject to
approval by the department.
(b) Managed care program (MCP) means a program operating in a social
services district in which MA recipients receive MA services, including case management
services, directly and indirectly (including by referral) from managed care providers.
(c) Managed care provider means an entity that provides or arranges for
the provision of MA services, including case management, to participants directly or
indirectly (including by referral). These entities include, but are not limited to,
physicians, nurse practitioners, hospitals, diagnostic and treatment centers (e.g.
clinics), those entities authorized to operate under Article 28 or 44 of the Public Health
Law, facilities licensed under Article 31 of the Mental Hygiene Law, primary care
capitation providers, physician case management providers, and other providers of
comprehensive health services authorized to provide such services as part of an MCP.
(d) Medical services provider means a physician, nurse, nurse
practitioner, nurse midwife, dentist, optometrist or other licensed health care provider
who is authorized to provide MA services.
(e) Participant means an MA recipient who receives or is required to
receive MA services from a managed care provider.
(f) Primary care practitioner means a physician or nurse practitioner
who provides primary care to and manages the medical and health care services of a
participant served by a managed care provider. The primary care practitioner may also
serve as the managed care provider.
(g) Social services district means a social services district or two or
more social services districts that join together in combination to develop and submit a
managed care plan, and if the plan is approved, implement and operate the MCP.