Conn. Agencies Regs. § 17b-262-713

Current through December 27, 2024

Section 17b-262-713 - Definitions

As used in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(2) "Client" means a person eligible for goods or services under the Medicaid program;

(3) "Commissioner" means the Commissioner of Social Services or his or her designee;

(4) "Department" means the Department of Social Services or its agent;

(5) "Documented in writing" means handwritten, typed or computer printed;

(6) "EPSDT (Early & Periodic Screening & Diagnostic Treatment) special services" means services provided in accordance with subdivision 1905 (r) of the Social Security Act;

(7) "Home" means the client's place of residence, including a boarding home, community living arrangement or residential care home. Home does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(8) "Hospital" means "short-term hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(9) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(10) "Licensed practitioner" means an individual who is licensed by the Connecticut Department of Public Health, another state, District of Columbia or the Commonwealth of Puerto Rico and is acting within his or her scope of practice under Connecticut state law in prescribing a medical or surgical supply;

(11) "Medical and surgical supplies" or "supply" means treatment products that:

(A) are fabricated primarily and customarily to fulfill a medical or surgical purpose;

(B) are used in the treatment or diagnosis of specific medical conditions;

(C) are generally not useful in the absence of illness or injury; and

(D) are generally not reusable and are disposable.

(12) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(13) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;

(14) "Medical necessity" or "medically necessary" means health care needed to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(15) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time;

(16) "Prescription" means an original order issued by a licensed practitioner that is documented in writing and signed and dated by the licensed practitioner issuing the order;

(17) "Prior authorization" or "PA" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(18) "Provider" means a vendor or supplier of medical and surgical supplies who is enrolled with the department as a supplier of medical and surgical supplies;

(19) "Provider agreement" means the signed, written contractual agreement between the department and the provider; and

(20) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, usual and customary shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

Conn. Agencies Regs. § 17b-262-713

Adopted effective May 11, 2009