Conn. Agencies Regs. § 17b-262-652

Current through December 27, 2024

Section 17b-262-652 - Definitions

For the purposes of sections 17b-262-651 through 17b-262-660, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1)"Border Hospital" means an out-of-state general hospital which has a common medical delivery area with the State of Connecticut and is deemed a border hospital by the department on a hospital by hospital basis.

(2)"Client" means a person eligible for goods or services under the department's Medicaid Program.

(3)"Commissioner" means the Commissioner of Social Services appointed pursuant to section 17b-1(a) of the Connecticut General Statutes.

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

(5)"Dialysis" means dialysis as defined in 42 CFR 405.2102.

(6)"Freestanding Dialysis Clinic" means those centers licensed by the Department of Public Health (DPH) and certified, pursuant to section 19-13-D55a of the Regulations of Connecticut State Agencies, to provide dialysis services.

(7)"General Hospital" means a short-term acute care hospital having facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment of a wide range of acute conditions, including injuries. This includes a children's general hospital. It shall also include a border hospital.

(8)"HealthTrack Services" means the services described in section 1905(r) of the Social Security Act.

(9)"HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with section 1905(r)(5) of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(10)"Home" means the client's place of residence which includes a boarding home or residential care home. Home does not include a hospital, chronic disease hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).

(11)"Interperiodic Encounter" means any medically necessary visit to a Connecticut Medicaid provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(12)"Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(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 medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(14)"Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act.

(15)"Medical Necessity or Medically Necessary" means health care provided 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 prevent a medical condition from occurring.

(16)"Medical Record" means medical record as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is part of the Public Health Code.

(17)"Physician" means a physician licensed pursuant to section 20-1 of the Connecticut General Statutes or a doctor of osteopathy licensed pursuant to section 20-17 of the Connecticut General Statutes.

(18)"Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(19)"Provider" means:

(A) a physician;

(B) a general hospital-inpatient or outpatient; or

(C) a freestanding dialysis clinic licensed by the Department of Public Health (DPH) and certified, pursuant to section 19-13-D55a of the Regulations of Connecticut State Agencies, to provide dialysis services.

(20)"Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(21)"State Plan" means the document which contains the services covered by the Connecticut Medicaid Program in compliance with 42 CFR(430)(B).

Conn. Agencies Regs. § 17b-262-652

Adopted effective May 10, 2000