Section R9-22-501. General Provisions and Standards - Related Defi- nitions

In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

“Quality management” means a process used by professional health personnel through a formal program involving multiple organizational components and committees to:

Assess the degree to which services provided conform to desired medical standards and practices; and

Quality improvement or maintenance of care and ser- vices.

“Quality Improvement” means a process designed to achieve, through ongoing measurements and intervention, significant improvement that is sustained over time, in the areas of clini- cal care and non-clinical care and is expected to have a favor- able  effect  on  health  outcomes  and  member  satisfaction. Quality Improvement includes focusing organizational efforts on improving performance and utilizing data to develop inter- vention strategies to improve performance and outcomes. “Utilization management/review” means a methodology used by professional health personnel to assess the medical indica- tions, appropriateness, and efficiency of care provided. Utili- zation  management  applies  to  a  contractor’s  process  to evaluate and approve or deny the medical necessity, appropri- ateness, efficacy and efficiency of health care services, proce- dures, or settings. Utilization review includes processes for prior authorization, concurrent review, retrospective review, and case management.

Historical Note

Adopted as an emergency effective May 20, 1982, pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-501 adopted as an emergency now adopted as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22-501 repealed, former Section R9-22-502 renumbered and adopted with- out change as Section R9-22-501 effective October 1, 1983 (Supp. 83-5). Former Section R9-22-501 repealed, former Section R9-22-526 renumbered and amended as Section R9-22-501 effective October 1, 1985 (Supp. 85-

5). Amended effective December 8, 1997 (Supp. 97-4). Section repealed; new Section made by final rulemaking at 11 A.A.R. 4277, effective December 5, 2005

(Supp. 05-4). Amended by final rulemaking at 14 A.A.R.

4330, effective January 3, 2009 (Supp. 08-4).