Conn. Agencies Regs. § 17b-262-631

Current through December 27, 2024

Section 17b-262-631 - Definitions

For the purposes of sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Advanced practice registered nurse" or "APRN" means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(2) "Audiologist" means a person licensed to practice audiology pursuant to chapter 397a of the Connecticut General Statutes and who meets the definition of "qualified audiologist" in 42 CFR 440.110(c)(3);

(3) "Audiology" means evaluation and treatment provided by an audiologist;

(4) "Border provider" has the same meaning as provided in section 17b-262-523 of the Regulations of Connecticut State Agencies;

(5) "Chronic disease hospital" has the same meaning as provided in section 19a-550 of the Connecticut General Statutes;

(6) "Client" means a person eligible for goods or services under Medicaid;

(7) "Commissioner" means the Commissioner of Social Services or the commissioner's agent;

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

(9) "Early and Periodic Screening, Diagnostic and Treatment Special Services" or "EPSDT Special Services" means services that are not otherwise covered under Medicaid but which are nevertheless covered as EPSDT services for Medicaid-eligible children pursuant to 42 USC 1396d(r)(5) when the service is medically necessary, the need for the service is identified in an EPSDT screen, the service is provided by a participating provider and the service is a type of service that may be covered by a state Medicaid agency and qualifies for federal reimbursement under 42 USC 1396d;

(10) "Home" means the client's place of residence, which includes a boarding home or residential care home. Home does not include a hospital or long-term care facility;

(11) "Hospital" means a "short-term hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies. It shall also include an out-of-state hospital or a hospital that is a border provider;

(12) "Independent therapist" means an audiologist, physical therapist, occupational therapist or speech pathologist practicing in the community independently and not associated with a hospital, long-term care facility, clinic, home health agency or any other health care provider;

(13) "Independent therapy" means those services provided by an independent therapist, a physical therapy assistant or an occupational therapy assistant;

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

(15) "International Classification of Diseases" or "ICD" means the most recent system of disease classification established by the World Health Organization or such other disease classification system that the department requires providers to use when submitting Medicaid claims;

(16) "Licensed practitioner" means a physician, a physician assistant, an advanced practice registered nurse or a podiatrist providing services within the licensed practitioner's scope of practice under state law;

(17) "Long-term care facility" means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include:

(A) nursing facilities;

(B) inpatient chronic disease hospitals; and

(C) intermediate care facilities for the mentally retarded;

(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 necessity" or "medically necessary" have the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(20) "Nursing facility" has the same meaning as provided in 42 USC 1396r(a) and is licensed pursuant to section 19-13-D8t of the Regulations of Connecticut State Agencies as a chronic and convalescent home or a rest home with nursing supervision;

(21) "Occupational therapist" has the same meaning as provided in section 20-74a(2) of the Connecticut General Statutes;

(22) "Occupational therapy" means services provided by an occupational therapist or an occupational therapy assistant and that meet the definition of occupational therapy in 42 CFR 440.110(b);

(23) "Occupational therapy assistant" has the same meaning as provided in section 20-74a(3) of the Connecticut General Statutes;

(24) "Physical therapist" has the same meaning as provided in section 20-66 of the Connecticut General Statutes;

(25) "Physical therapy assistant" has the same meaning as provided in section 20-66 of the Connecticut General Statutes;

(26) "Physical therapy" means the evaluation and treatment provided by a physical therapist or physical therapy assistant in accordance with 42 CFR 440.110(a);

(27) "Physician" means a person licensed pursuant to section 20-13 of the Connecticut General Statutes;

(28) "Physician assistant" has the same meaning as provided in section 20-12a(5) of the Connecticut General Statutes;

(29) "Podiatrist" means a person licensed to practice podiatric medicine pursuant to chapter 375 of the Connecticut General Statutes;

(30) "Prior authorization" 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;

(31) "Provider" means an independent therapist enrolled with Medicaid;

(32) "Provider agreement" means the signed, written agreement between the department and the provider for enrollment in Medicaid;

(33) "Speech pathologist" means a "licensed speech and language pathologist" as defined in section 20-408 of the Connecticut General Statutes;

(34) "Speech pathology services" means the evaluation and treatment provided by a speech pathologist in accordance with 42 CFR 440.110(c); and

(35) "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" means the median charge. Token charges for charity patients and other exceptional charges shall be excluded when calculating the usual and customary charge.

Conn. Agencies Regs. § 17b-262-631

Adopted effective December 1, 2000; Amended September 6, 2012