Section 501-A. Definitions.
The following words and phrases when used in this article shall have the meanings given to them in this section unless the context clearly indicates otherwise:
"All Patient Refined Diagnosis Related Groups." A version of Diagnosis Related Groups that further subdivide the Diagnosis Related Groups into four severity-of-illness and four risk-of-mortality subclasses within each Diagnosis Related Groups.
"Diagnosis Related Groups." A classification system that uses patient discharge information to classify patients into clinically meaningful groups.
"Hospital." A public or private institution licensed as a hospital under the laws of this Commonwealth that participates in the Medicaid program.
"Managed care organization." A licensed managed care organization with whom the department has contracted to provide or arrange for services to a Medicaid recipient.
"Medicaid program." The Commonwealth's medical assistance program authorized under Article IV.
"Potentially avoidable admission." An admission of an individual to a hospital or long-term care facility that may have reasonably been prevented with adequate access to ambulatory care or health care coordination.
"Potentially avoidable complication." A harmful event or negative outcome with respect to an individual, including an infection or surgical complication, that:
(1) occurs after the person's admission to a hospital or long-term care facility; and
(2) may have resulted from the care, lack of care or treatment provided during the hospital or long-term care facility stay rather than from a natural progression of an underlying disease.
"Potentially avoidable emergency visit." Treatment of an individual in a hospital emergency room or freestanding emergency medical care facility for a condition that may not require emergency medical attention because the condition could be or could have been treated or prevented by a physician or other health care provider in a nonemergency setting.
"Potentially avoidable event." Any of the following:
(1) A potentially avoidable admission.
(2) A potentially avoidable complication.
(3) A potentially avoidable emergency visit.
(4) A potentially avoidable readmission.
(5) A combination of the events listed under this definition.
"Potentially avoidable readmission." A return hospitalization of an individual within a period specified by the department that may have resulted from a deficiency in the care or treatment provided to the individual during a previous hospital stay or from a deficiency in posthospital discharge follow-up. The term does not include a hospital readmission necessitated by the occurrence of unrelated events after the discharge. The term includes the readmission of an individual to a hospital for:
(1) The same condition or procedure for which the individual was previously admitted.
(2) An infection or other complication resulting from care previously provided.
(3) A condition or procedure that indicates that a surgical intervention performed during a previous admission was unsuccessful in achieving the anticipated outcome.
(501-A added June 22, 2018, P.L.258, No.40)