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.
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