Mont. Admin. r. 37.85.1103

Current through Register Vol. 23, December 6, 2024

Rule 37.85.1103 - DEFINITIONS

For purposes of the Montana Medicaid Provider Incentive Program (MMPIP), the following definitions apply:

(1) "Act" means the Health Information Technology for Economic and Clinical Health Act or "HITECH" Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5 (2009).

(2) "Electronic Health Records" (EHR) means a systematic collection of electronic health information about individual patients or populations. For the purposes of these rules, the term "EHR" will refer to an electronic health record information system that is certified by the Certification Commission for Health Information Technology and therefore qualifies for the Montana Medicaid Provider Incentive Program.

(3) "Eligible hospital" (EH) means an acute care hospital (including critical access hospitals and cancer hospitals) with at least 10% Medicaid patient volume and a children's hospital with no Medicaid patient volume requirements. An EH must have a Centers for Medicare and Medicaid (CMS) Certification Number with the last four digits in the series 0001-0879 as defined in 42 CFR 495.302 (2011).

(4) "Eligible hospital patient volume encounter" means the services rendered during one day by an eligible hospital to individuals, per inpatient discharges, or in an emergency department, for which Medicaid, or a Medicaid demonstration projection under 42 USC 1315 (2011), paid all or part of the fee or paid all or part of the individual's premiums, copayments, and/or cost-sharing.

(5) "Eligible provider" (EP) means a physician, dentist, nurse practitioner, certified nurse midwife, physician assistant practicing at a federally qualified health center (FQHC) or rural health clinic (RHC) so led by a physician assistant, critical access hospital, or acute care hospital.

(6) "Eligible provider patient volume encounter" means services rendered during one day by an eligible provider to individuals for which Medicaid, or a Medicaid demonstration project under 42 USC 1315 (2011), paid part or all of the fee or paid all or part of the individual's premiums, copayments, and/or cost-sharing.

(7) "Encounter" means a face-to-face meeting between a patient and health care provider taking place on any one day and at a single location.

(8) "Federally qualifying health clinics" (FQHC) means an entity defined at 42 USC 1395 x(aa)(3) and 42 USC 1395 y(aa)(3). This includes an outpatient health program or facility operated by a tribe or tribal organization receiving funds under Title V of the Indian Health Care Improvement Act for the provision of primary health services. In considering this definition, it should be noted that programs meeting FQHC requirements commonly include the following (but must be certified and meet all requirements stated above):

(a) Community Health Centers;

(b) Migrant Health Centers;

(c) Healthcare for the Homeless Programs;

(d) Public Housing Primary Care Programs;

(e) Federally Qualified Health Center Look-Alikes; and

(f) Tribal Health Centers.

(9) "Meaningful use" means the use of a certified EHR in a meaningful manner. Examples of meaningful use include: e-Prescribing, the use of certified EHR technology for electronic exchange of health information to improve quality of health care, and the use of certified EHR technology to submit clinical quality or other measures.

(10) "Montana Medicaid fiscal agent" means a contractor hired by the Department of Public Health and Human Services to provide a variety of services associated with the operation of the state Medicaid Program including claims processing, provider services, and other functionality.

(11) "Montana Medicaid Management Information System" (MMIS) means an automated system used by the department to administer various aspects of the Montana Medicaid Program, including claims processing and payment.

(12) "National Level Repository" (NLR) means a new record system authorized by provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) ( P.L. 111-5) and designed to collect, maintain, and process information that is required for the Medicaid EHR Incentive Program.

(13) "Needy individual patient volume encounter" means:

(a) a patient for whom Medicaid, Healthy Montana Kids (HMK) Plan, or a demonstration project under 42 USC 1315 (2011), paid for part or all of the services or paid all or part of the individual's premiums, copayments, and/or cost sharing; or

(b) services rendered to an individual on any one day on a sliding scale or that were uncompensated.

(14) "Program" means the Montana Medicaid Provider Incentive Program (MMIP).

(15) "Rural Health Clinic (RHC) means a clinic that is certified under 42 USC 1935 x(aa)(2) to provide care in underserved areas, and therefore, to receive cost-based Medicare and Medicaid reimbursements.

Mont. Admin. r. 37.85.1103

NEW, 2011 MAR p. 1374, Eff. 7/29/11.

53-6-113, MCA; IMP, 53-6-111, MCA;