Conn. Agencies Regs. § 17b-262-995

Current through December 27, 2024

Section 17b-262-995 - Definitions

As used in section 17b-262-994 to section 17b-262-1004, inclusive, of the Regulations of Connecticut State Agencies:

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

(2) "Allied health professional" or "AHP" means:

(A) A licensed or certified practitioner performing within his or her scope of practice in any of the professional and occupational license or certification categories in Chapters 376b, 378, 379a, 383a, 383c, and 384b of the Connecticut General Statutes and shall include alcohol and drug counselors, certified dietitians, certified nutritionists, dental hygienists, marital and family therapists, professional counselors, and registered nurses;

(B) A licensed master social worker working under the professional supervision of a physician, APRN, psychologist, licensed marital and family therapist, LCSW or a licensed professional counselor in accordance with section 20-195m of the Connecticut General Statutes; and

(C) A license-eligible individual as defined in subdivision (30) of this section;

(3) "Baseline encounter rate" means the encounter rate calculated for the initial or first year under the prospective payment system;

(4) "Behavioral health encounter" means an encounter between a client and a practitioner listed in subdivision (5) of this section for the provision of covered behavioral health services;

(5) "Behavioral health service" means a preventive, diagnostic, therapeutic, rehabilitative or palliative item or service provided by:

(A) A physician, psychiatric APRN, psychologist or LCSW acting within the practitioner's scope of practice as defined in chapters 370, 378, 383 and 383b of the Connecticut General Statutes;

(B) An alcohol and drug counselor, licensed master social worker, marital and family therapist or professional counselor acting within the practitioner's scope of practice, as defined in title 20 of the Connecticut General Statutes; or

(C) An unlicensed or non-certified individual, who is otherwise qualified to perform services under the applicable licensure category sections of the Regulations of Connecticut State Agencies, working under the direct supervision of a licensed AHP. Supervision of unlicensed or non-certified individuals shall be provided in accordance with sections 20-74s, 20-195c, 20-195m, 20-195n and 20-195dd of the Connecticut General Statutes;

(6) "Certified dietitian" or "certified nutritionist" means a person certified as a dietitian or nutritionist pursuant to section 20-206n or 20-206o of the Connecticut General Statutes;

(7) "Change in the scope of service" means a change in the type, intensity, duration or amount of services provided by a FQHC. A change in the cost of the service alone is not considered a change in the scope of service;

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

(9) "Chiropractic services" means the services described in 42 CFR 440.60 and subdivision (1) of section 20-24 of the Connecticut General Statutes:

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

(11) "Clinical psychologist" means a person licensed pursuant to sections 20-188 and 20-190 of the Connecticut General Statutes;

(12) "CMS-1500" means the official standard Medicare and Medicaid health insurance claim form required by the Center for Medicare and Medicaid services of the United States Department of Health and Human Services;

(13) "Commissioner" means the commissioner of Social Services or the commissioner's designee;

(14) "Dental encounter" means an encounter between a client and a dentist or dental hygienist for the provision of covered dental services;

(15) "Dental hygienist" means a person licensed pursuant to section 20-126j of the Connecticut General Statutes;

(16) "Dental service" means any diagnostic, preventive, or corrective procedures administered by or under the direct supervision of a dentist;

(17) "Dentist" means a person licensed pursuant to Chapter 379 of the Connecticut General Statutes;

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

(19) "Dietetic services" means services provided by a certified dietitian or certified nutritionist for the management of a person's nutritional needs, including the evaluation and monitoring of nutritional status, nutrition counseling, dietetic therapy, dietetic education, and dietetic research necessary for the management of a recipient's nutritional needs;

(20) "Early and Periodic Screening, Diagnostic and Treatment Services" or "EPSDT services" means the services provided in accordance with the requirements of 42 USC 1396a(a) (43), 42 USC 1396d (r) and 42 USC 1396d(a) (4) (B) and implementing federal regulations found in 42 CFR 441, Subpart B and subsection (j) of section 17b-261 of the Connecticut General Statutes;

(21) "Early and Periodic Screening, Diagnostic and Treatment Special Services" or "EPSDT Special Services" means services provided in accordance with 42 USC 1396d(r) (5), as amended from time to time;

(22) "Encounter" means a face-to-face visit between a client and health professional or an allied health professional for medically necessary services and includes the client's visit to the FQHC and all services and supplies incidental to the health professional's services. Visits with more than one health professional or allied health professional or multiple visits with the same health professional or allied health professional that take place on the same day shall be considered one encounter, except under either of the following circumstances:

(A) A client, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment; or

(B) A client has different types of encounters (medical, behavioral health and dental) for different diagnoses on the same day;

(23) "Encounter rate" means the all-inclusive PPS rate that the Department reimburses a FQHC for an encounter pursuant to 42 USC 1396a(bb);

(24) "Federally qualified health center" or "FQHC" has the same meaning as provided in 42 USC 1396d (l) (2) (B);

(25) "Healthcare common procedure coding system" or "HCPCS" means the set of health care procedure codes based on the American Medical Association's current procedural terminology;

(26) "Health professional" means a physician, physician assistant, advanced practice registered nurse, nurse midwife, chiropractor, ophthalmologist, optometrist, podiatrist, dentist, clinical psychologist, licensed clinical social worker or psychiatrist;

(27) "Health Resources and Services Administration" or "HRSA" means the division of the U.S. Department of Health and Human Services that approves grant awards to and scope of projects for FQHCs;

(28) "Licensed clinical social worker" or "LCSW" means a person licensed pursuant to section 20-195n of the Connecticut General Statutes;

(29) "Licensed master social worker" or "LMSW" means a person licensed pursuant to 20-195n of the Connecticut General Statutes;

(30) "License-eligible" means a person whose education, training, skills and experience satisfy the criteria, including accumulation of all supervised service hours, for any of the professional and occupational license or certification categories in Chapters 370, 376b, 379a, 383, 383a, 383b and 383c of the Connecticut General Statutes, and has applied for but not yet passed the licensure exam;

(31) "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;

(32) "Medical encounter" means an encounter between a client and a health professional or an allied health professional for the provision of covered medical services;

(33) "Medical service" means a preventive or diagnostic service provided by a physician, physician assistant, advanced practice registered nurse or nurse midwife for the treatment of an illness or injury;

(34) "Medically necessary" and "medical necessity" have the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(35) "Nurse midwife" means a person licensed under section 20-86c of the Connecticut General Statutes;

(36) "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;

(37) "Optometrist" means a person licensed pursuant to Chapter 380 of the Connecticut General Statutes to practice optometry as delineated in subdivisions (1), (2) and (3) of subsection (a) of section 20-127 of the Connecticut General Statutes;

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

(39) "Physician assistant" or "PA" means a person licensed pursuant to section 20-12b of the Connecticut General Statutes;

(40) "Podiatric services" means services provided by a podiatrist within the scope of practice under Chapter 375 of the Connecticut General Statutes;

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

(42) "Point-of-care testing" means medical testing at or near the site of patient care and includes, but is not limited to, blood glucose testing, blood gas and electrolyte analysis, rapid coagulation testing, rapid cardiac markers diagnostics, drugs-of-abuse screening, urine strips testing, pregnancy testing, fecal occult blood analysis, food pathogens screening, hemoglobin diagnostics, infectious disease testing and cholesterol screening;

(43) "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;

(44) "PPS" means the prospective payment system under 42 U.S.C. 1396a(bb);

(45) "Registered Nurse" means a person licensed pursuant to section 20-93 of the Connecticut General Statutes;

(46) "Registration" means the process of notifying the department of the initiation of a service, which includes providing information regarding the evaluation findings and plan of care;

(47) "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;

(48) "Scope of project" means the document that delineates the FQHC's approved service sites, services, providers, service area and target population for which grant funds have been approved by HRSA under section 330 of the Public Health Service Act;

(49) "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;

(50) "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 neuropathies involving the feet, which would justify coverage of routine foot care;

(51) "Under the direct supervision" means that a health professional or a licensed AHP:

(A) Provides weekly supervision of the work performed by unlicensed clinical staff or non-certified staff or individuals in training;

(B) Provides a minimum of monthly supervision for the work performed by certified staff; and

(C) Accepts primary responsibility for the health services performed by the unlicensed, certified or non-certified staff or individuals in training.

(52) "Under the professional supervision" has the same meaning as provided in section 20-195m of the Connecticut General Statutes.

Conn. Agencies Regs. § 17b-262-995

Effective May 13, 2015