Conn. Agencies Regs. § 17b-262-560

Current through December 27, 2024

Section 17b-262-560 - Definitions

For the purposes of sections 17b-262-559 through 17b-262-571 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

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

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

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

(5) "Doctor of Osteopathy" means a doctor of osteopathy licensed pursuant to section 20-17 of the Connecticut General Statutes.

(6) "Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)" means the services described in subsection (r) of section 1905 of the Social Security Act.

(7) "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.

(8) "Fees" means the rates for services, treatments, and drugs administered by ophthalmologists, optometrists, and opticians which shall be established by the commissioner of the department and contained in the department's fee schedules.

(9) "Incomplete Eye Exam" means an annual eye exam which is not completed since the preliminary findings reveal that visual analysis is not indicated.

(10) "Interperiodic Encounter" means any medically necessary visit to a Connect-icut Medical Assistance 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.

(11) "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).

(12) "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.

(13) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(14) "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.

(15) "Medical Record" means the definition contained in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is also the Public Health Code.

(16) "Modified Lens Prescription" means a prescription given to a client because of:

(A) a radical change in the prescription;

(B) a large initial prescription; or

(C) amblyopia, latent hyperopia, or inadequate care previously received.

(17) "Ophthalmologist" means a physician licensed pursuant to Chapter 370 of the Connecticut General Statutes, who within his or her scope of practice as defined by state law, specializes in the branch of medicine dealing with the structure, functions, pathology, and treatment of the eyes. The practice includes the use of surgery, x-ray, photocoagulation, ionizing radiation, and drugs for examination of the eyes.

(18) "Optician" means an individual licensed pursuant to section 20-145 of the Connecticut General Statutes having a knowledge of optics and is skilled in the technique of producing and reproducing ophthalmic lenses and kindred products and who, within his or her scope of practice as defined by state law, prepares and dispenses ophthalmic lenses and products to correct visual defects.

(19) "Optometrist" means an individual licensed pursuant to Chapter 380 of the Connecticut General Statutes to practice optometry as delineated in subsections (a) (1) and (2) of section 20-127 of the Connecticut General Statutes.

(20) "Physician" means a physician licensed pursuant to section 20-10 of the Connecticut General Statutes.

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

(22) "Progressive Myopia" means a known progressive myopia, changing .75 diopters in the past six months.

(23) "Provider" means a licensed ophthalmologist, optometrist, or optician.

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

(25) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

(26) "Usable Lens" means a lens which is not scratched or otherwise defective so as to impair use or endanger the wearer.

(27) "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. When calculating the median charge, token charges for charity patients and other exceptional charges are to be excluded.

Conn. Agencies Regs. § 17b-262-560

Adopted effective March 6, 1998; Amended June 11, 2003