Conn. Agencies Regs. § 17b-262-620

Current through December 27, 2024

Section 17b-262-620 - Definitions

As used in section 17b-262-619 to section 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Acute" means symptoms that are severe and have a rapid onset and short course;

(2) "Admission" means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;

(3) "Border provider" means an out-of-state provider who routinely serves clients and is deemed a border provider by the department on a provider by provider basis;

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

(5) "Client" means a person eligible for goods or services under the department's Medicaid program;

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

(7) "Consultation" means those services rendered by a podiatrist or other practitioner whose opinion or advice is requested by the client's podiatrist or other appropriate source in the evaluation or treatment of the client's illness;

(8) "Customized item" means an item or material adapted through modification to meet the specific needs of a particular client;

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

(10) "Early and Periodic Screening, Diagnostic and Treatment services" or "EPSDT" means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(11) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part;

(12) "Freestanding clinic" means "freestanding clinic" as defined in section 171B of the department's Medical Services Policy for clinic services;

(13) "General hospital" means "general hospital" as defined in section 17-134d-80 of the Regulations of Connecticut State Agencies;

(14) "Home" means the client's place of residence, including, but not limited to, 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 (ICFs/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(15) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for persons with mental retardation 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;

(16) "Legend device" means "legend device" as defined in section 20-571 of the Connecticut General Statutes;

(17) "Legend drug" means "legend drug" as defined in section 20-571 of the Connecticut General Statutes;

(18) "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, as amended from time to time;

(19) "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;

(20) "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 to prevent a medical condition from occurring;

(21) "Medical record" means "medical record" as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies;

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

(23) "Out-of-state provider" means a provider that is located outside Connecticut and is not a border provider;

(24) "Physician" means a person licensed pursuant to chapter 370 of the Connecticut General Statutes;

(25) "Podiatric Services" means services provided by a podiatrist within the scope of practice as defined by state law, including chapter 375 of the Connecticut General Statutes;

(26) "Podiatrist" means a doctor of podiatric medicine licensed pursuant to section 20-54 of the Connecticut General Statutes;

(27) "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;

(28) "Provider" means a podiatrist or a podiatrist group enrolled in Medicaid;

(29) "Quality of care" means the evaluation of medical care to determine if it meets the professionally recognized standards of acceptable medical care for the condition and the client under treatment;

(30) "Routine foot care" means clipping or trimming of normal or mycotic toenails; debridement of the toenails that do not have onychogryposis or onychauxis; shaving, paring, cutting or removal of keratoma, tyloma or heloma; and nondefinitive shaving or paring of plantar warts except for the cauterization of plantar warts;

(31) "Simple foot hygiene" means self-care including, but not limited to: observation and cleansing of the feet; use of skin creams to maintain skin tone of both ambulatory and bedridden patients; nail care not involving professional attention; and prevention and reduction of corns, calluses and warts by means other than cutting, surgery or instrumentation;

(32) "Systemic condition" means the presence of a metabolic, neurologic, or peripheral vascular disease, including, but not limited to: diabetes mellitus, arteriosclerosis obliterans, Buerger's disease, chronic thrombophlebitis and peripheral neu-ropathies involving the feet, which would justify coverage of routine foot care;

(33) "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; and

(34) "Utilization review" means the evaluation of the necessity and appropriateness of medical services and procedures as defined in section 17-134d-80 of the Regulations of Connecticut State Agencies.

Conn. Agencies Regs. § 17b-262-620

Adopted effective February 11, 2009