108D-1. Definitions.

The following definitions apply in this Chapter, unless the context clearly requires otherwise:

(1) Applicant. - A provider of mental health, intellectual or developmental disabilities, and substance abuse services who is seeking to participate in the closed network of one or more local management entity/managed care organizations.

(2) Closed network. - The network of providers that have contracted with a local management entity/managed care organization to furnish mental health, intellectual or developmental disabilities, and substance abuse services to enrollees.

(3) Contested case hearing. - The hearing or hearings conducted at the Office of Administrative Hearings under G.S. 108D-15 to resolve a dispute between an enrollee and a local management entity/managed care organization about a managed care action.

(4) Department. - The North Carolina Department of Health and Human Services.

(5) Emergency medical condition. - As defined in 42 C.F.R. 438.114.

(6) Emergency services. - As defined in 42 C.F.R. 438.114.

(7) Enrollee. - A Medicaid beneficiary who is currently enrolled with a local management entity/managed care organization.

(8) Local Management Entity or LME. - As defined in G.S. 122C-3(20b).

(9) Local Management Entity/Managed Care Organization or LME/MCO. - As defined in G.S. 122C-3(20c).

(10) Managed care action. - An action, as defined in 42 C.F.R. 438.400(b).

(11) Managed Care Organization or MCO. - As defined in 42 C.F.R. 438.2.

(12) Mental health, intellectual or developmental disabilities, and substance abuse services or MH/IDD/SA services. - Those mental health, intellectual or developmental disabilities, and substance abuse services covered under a contract in effect between the Department of Health and Human Services and a local management entity to operate a managed care organization or prepaid inpatient health plan (PIHP) under the 1915(b)/(c) Medicaid Waiver approved by the federal Centers for Medicare and Medicaid Services (CMS).

(13) Network provider. - An appropriately credentialed provider of mental health, intellectual or developmental disabilities, and substance abuse services that has entered into a contract for participation in the closed network of one or more local management entity/managed care organizations.

(14) Notice of managed care action. - The notice required by 42 C.F.R. 438.404.

(15) Notice of resolution. - The notice described in 42 C.F.R. 438.408(e).

(16) OAH. - The North Carolina Office of Administrative Hearings.

(17) Prepaid Inpatient Health Plan or PIHP. - As defined in 42 C.F.R. 438.2.

(18) Provider of emergency services. - A provider that is qualified to furnish emergency services to evaluate or stabilize an enrollee's emergency medical condition.